HCA Houston Healthcare Clear Lake

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to document, analyze, and identify possible preventative measures following an incident that involved a patient leaving AMA (against medical advice) and being escorted out of the building.

[citing Patient # 4]

Findings included:

TX 173

Review of facility policy titled Risk Management-Notification of Occurrences,dated 03/2016, showed the policy...provided a mechanism for reporting unusual occurrences and operational variances not consistent with normal hospital operations and patient treatment expectations... The policy showed that:

*The online reporting system should be used to document patient complaints affecting quality.

* Employees are responsible to document & report occurrences.

* Each incident should be reported to the immediate supervisor as soon as possible, but no later than the end of the shift.

* Department manager/supervisor completes their portion of the report with the goal of 5 days of the event; no later than 15 days from the event.

* Risk Manager reviews & analysis the report and reports trends to the Patient Safety Committee.

* When applicable the risk manger will facilitate an Apparent Cause Analysis or a Serious Event Analysis whichever is appropriate.

~~~~~~~~~~

Review of intake # TX 173 detailed an account that involved Patient #4; a visitor; and various facility staff members, including administrative representative. The intake narrative described allegations related to pain management & allegations the facility mishandled a situation resulting in security escorting the patient & family out of the building. Patient # 4 was hospitalized [DATE] with pneumonia.

Record review of Patient # 4's clinical record showed she was a [AGE] year old female admitted to the facility on [DATE] with fever and cough; bilateral pneumonia.

Record review of nursing documentation dated 09/29/19 at 2140 showed lengthy description of interactions among Patient #4, a visitor, nursing staff, and administrator on site (AOS). Nursing documentation described an escalating situation:facility staff attempted to discuss Patient # 4's concerns about pain management. It was documented in the record that Patient # 4's visitor became hostile; he was informed security was going to be called to escort him off the property. Documentation showed Patient # 4 was not satisfied with how the situation was handled. Patient # 4 removed her pulse oximeter and the IV (intravenous) line from her arm and began yelling. Patient # 4 requested to leave and refused to sign the against medical advice (AMA) form. Security was called and Patient # 4 was escorted from the building

Record review of facility occurrence / incident log for 2019 failed to reveal a any documentation related to the incident involving Patient # 4.

Interview on 11-21-19 at 2:40 PM with Staff I, nurse manager, she stated the incident should have been documented in the online system as a variance.

Interview on 11-21-19 at 12:40 PM with Staff E, Patient Safety Director, she stated this incident should have been entered as an occurrence so that it could have been analyzed for possible improvement opportunities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to monitor a patient appropriately after administering intravenous medication in the emergency room (ER). [citing Patient # 5 ]

Findings included:

TX 441

Review of facility policy titled Medication Administration-Adult & Pediatric,dated 01/2017, showed staff were expected to use their professional judgement to assure medications were delivered in a safe manner. Staff was to take into account the nature and variability of the medication and the needs of the patients receiving the medication.

Review of complaint intake TX 441 showed an allegation that Patient # 5 was discharged (from ER) prior to knowing if there would be a drug interaction.

Review of the ER record of Patient # 5 showed she was a [AGE] year old female who (MDS) dated [DATE] at 22:03 with complaint of headache following an epidural injection earlier that day.

Review of Patient # 5's ER medication Administration Record (MAR), dated 4/18/19 showed the following:

a. Toradol 30 milligrams (mg) was administered IV at 1:48 AM;

b. Haldol 4 mg was administered IV at 1:50 AM.

Review of the Discharge Instructions for Patient # 5 showed that she signed the instructions and was discharged from the ER at 1:56 AM.

Interview on 11-21-19 at 2:30 PM with Staff K, ER nursing director, she stated that typically a patient should be observed for 15 to 30 minutes after an IV medication was administered. She went on to say if Haldol was administered IV, the patient should be kept for 30 minutes to observe for unexpected effects.

The ER nursing director said discharging a patient 6 minutes after administering IV Haldol was not acceptable.

Based on interview and record review the facility failed to notify patients timely regarding in 2 of 4 (ID # 8. 9) complaints and grievances reviewed.

Findings Included:

Record review of the facility policy Patient Grievances and Complaint Management dated 04/2016 stated:

If a grievance will not be resolved, or if the investigation is not or will not completed within seven (7) days, the complainant should be informed that the facility is still working to resolve the grievance and the facility will follow-up with a written response within twenty-one (21) days.

Record review revealed:

Patient (ID #8) complaint was received on 04/17/19 and received a final letter dated 05/23/2019 and did not received an acknowledgement letter.

Patient (ID #9) complaint was received on 04/26/2019 and received a final letter dated 05/23/2019 and did not received an acknowledgement letter.

Interview with the Director of Patient Safety (Staff # 74) on 09/04/2019 at 1254 who stated:

Our goal is to have a three-day turn-around time. We send out a letter to managers to address the complaint the same day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to ensure registered nurses were supervising and evaluating the nursing care to confirm orders were completed for 6 patients out of 12 (ID #1, 10, 11, 14, 15, 17) medical records reviewed.

Findings Included:

Record review of current facility policy Assessment/Reassessment dated 04/2019 stated: Nursing, Critical care: reassessment include intake and output, daily weights unless contraindicated. Inpatient Rehab: Intake and output will be documented every 12 hours. Inpatient RN assessment (page 24) includes systems review ... ... gastrointestinal...genitourinary ... integumentary

Record review of the medical record on 09/03/2019 and 09/04/2019 revealed the following: Patient (ID #1), was not turned every two hours from August 1, 2019 to September 5, 2019. The patient does not ambulate and can not turn without assistance.

Patient (ID # 1), had nutritional supplemental ordered 08/04/2019 of Glycerina and Nepro ordered, there is no documentation noted that the patient was given or received the supplement.

Patient (ID #1) was not weighted since the day of admission 07/31/2019 and the same weight was documented in the medical record 8 times.

Record review on 09/03/2019 of the medical record, of Patient (ID #10), revealed nutritional supplements ordered on [DATE] for Glucerna 3 times per day (TID) and Juven 2 times per day (BID). There was no documentation that the supplement was offered or consumed by the patient.

Record review on 09/03/2019 of the medical record, of Patient (ID # 11) revealed nutritional supplements ordered on [DATE] for Glucerna TID, and Javen BID. There was no documentation that the supplement was offered or consumed by the patient.

Record review on 09/03/2019 of the medical record, Patient (ID # 14) had an order dated 08/20/2019 to receive Ensure BID. There was no documentation that the supplement was offered or consumed by the patient.

Record review on 09/03/2019 of the medical record, Patient (ID # 15) had an order dated 08/30/2019 for Liquid Protein daily. There was no documentation that the supplement was offered or consumed by the patient.

Record review on 09/03/2019 of the medical record, Patient (ID # 17), had an order dated 08/30/2019 for strict intake and output (I & O). There was no documentation of I & O noted in the medical.

Interview on 09/03/2018 at 1:00 p.m. with the charge nurse, (Staff # 61) who stated there was no documentation of intake or that the patients were not turned every two hours.

Interview on 09/03/2019 at Interview 09/05/2019 at 2:30 p.m., Quality Director (Staff ID # 51), validated there were no current weights on the patient (ID # 1) documented in the medical record.

Based on review of patient medical records, hospital documents and interviews with staff the governing body failed to ensure the medical staff requirements were met as evidenced by the physician's failure to perform a complete medication reconciliation within 24 hours of admission. This resulted in the patient not receiving the correct dosage and frequency of home medications on 12/06/18, 12/07/18 and 12/08/18 in 1 of 5 patients. This was in violation of hospital policy.

The findings included:

The medical record for Patient #11 reviewed on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus revealed an H&P report dated 12/7/18 at 7:06am performed by Staff #34. The report stated the chief complaint was nausea and vomiting. The diagnosis, Assessment & Plan were UTI, Dehydration, nausea and vomiting, Bladder calculi with a Plan of Intravenous Fluids (IVF), antibiotics, urology evaluation if possible, no signs of obstructive uropathy, Physical Therapy (PT) /Occupational Therapy (OT), Resume home meds, anti-emetics, still nauseated.

The patient's IV fluids ordered in the ED dropped off after 24 hours of admission to the floor and were not reordered until 12/08/2018.

Note by Attending Physician, Staff #34 on 12/08/18 @ 2021 stated home meds were entered wrong. So when Dr. Singh continued med wrong dosage and meds were continued.

A review of the hospital policy titled Medication Reconciliation with a last reviewed date of 12/2018 stated in part The purpose of Medication Reconciliation is to accurately reconcile patient medications across the continuum of care ...Medication Reconciliation is completed to ensure that the patient is prescribed the appropriate medications upon admission to the facility, transfer between department, and discharge from the facility. B. Blanket orders such as continue all medications or resume home medication are not be accepted.

An interview was conducted on the morning of 02/13/2019 with Staff #26, Patient Safety Director. When Staff #26 was asked how are medications reconciled at the hospital. Staff #26 stated that Emergency Department nurses were to discuss all home medications with patients and family and they then enter the medications on the patient's record. She stated the ED physician can then either continue or discontinue the medications. She stated that all new nurses are getting medication reconciliation review training in their new hire orientation. Staff #26 stated she talked with Staff #35 who reported she reviewed Patient 11's chart and wrote orders prior to entering patient's room. Staff #26 stated Staff #35 restarted the patient's home medications with incorrect dosages of Prednisone. Staff #26 stated the intravenous fluids ordered by the ED physician were still on the medical record when Staff #35 first reviewed the chart on 12/06/18 but the ED order dropped off after 24 hours as per hospital policy. Staff #26 stated Staff #35 did not perform an assessment of the patient and did not write a progress note once she found out she was not a physician on the patient's insurance plan.

Based on review of patient medical records, hospital documents and interviews with staff the facility failed to ensure the patient and family rights to participate in her medical plan of care were enforced as evidenced by the lack of response of the physician and nurses to respond to patient's request to change medication from an evening to morning dosage due to increased pain in her arm noted on 12/07/18 @ 2001. The patient's daughter and other family members requested multiple times to have the attending physician phone them back to discuss the patient's plan of care, medications, and diet.

Findings were:

The medical record for Patient #11 reviewed on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus revealed nurse's notes dated 12/06/18, 12/07/18, 12/08/18 that stated the complainant, patient's daughter had called with multiple requests to speak with the Attending Physician, Staff #34 with concerns about Patient #11's care plan, medications, diet, and IV fluids. Patient #11 was admitted with a diagnosis of Dehydration on 12/05/18. IV fluids ordered in the ED dropped off after 24 hours of admission to the floor and were not reordered until 12/08/2018.

A clear liquid diet was ordered in the ED on 12/05/18 due to patient's complaints of nausea and vomiting.

A nurse note dated 12/8/18 noted that Attending Physician, Staff #34 was called to address that the patient's daughter and daughter-in-law wanted to speak with him about the patient's plan of care. She addressed the medical record had been updated correctly and an order was given to restart the medications. She informed Staff #34 that Patient #11 had been on a clear liquid diet since admission (2 days) and received order for a cardiac diet. Informed MD of the complainant's concern the patient was not on IV fluids when her admitting diagnosis was dehydration. As of this time there were no orders in the record to restart IV fluids. The nurse obtained an order for normal saline IV fluids @ 75ml/hr. The family was very upset they had not talked with a doctor as of this time.

An interview with Staff #26, Patient Safety Director was conducted on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus. Staff #26 acknowledged above documentation.

Based on observation, interviews, and review of the medical record, the facility violated the rights of patient #1. The facility failed to provide safety and dignity for patient #1. The surgeon staff #20 failed to document orders for abdominal midline wound care. Use ostomy appliance was documented on 7/25/18 in the progress note. The ostomy appliance was not applied to the abdominal wound of pt #1 until 7/28/2018. Three days after it was documented in the progress note and discuss with nursing. This caused potential for skin breakdown, infection, discomfort from foul smelling drainage, and mental anguish.

Findings included:

Review of progress notes per staff #20 surgeon reveal pt #1 was seen 7/25/18, 7/26/18, 7/28/18 by staff #20 the surgeon. Review of staff #20 progress note 7/25/18 1749, assessment/plan, advised nursing staff to place ostomy appliance over the site to record output and protect the skin. She continues to have foul-smelling drainage from her wound.

Review of staff #20 progress note 7/26/18 1839, Abdomen soft; purulent drainage from wound, less in volume, no odor today; pigtail drain from IR has SS fluid, no pus. Review of staff #20 progress note 7/28/18 0914, will consult ostomy nurse and plan to transfer to med/surg floor.

A telephone interview was conducted with staff #20 on 2/13/19 at 1:05 pm, staff #20 said he spoke to the nurses instructing them to obtain ostomy supplies for wound care.

Review of progress note, 7/28/18 at 1639 staff #21 NP ostomy. The midline abdomen incision dehiscence with large amount bilious drainage with fecal odor and slough at incision edges with wound penetrating into peritoneal cavity. Problem; 1. Abscess of abdominal cavity. 2. Open wound of abdominal wall with penetration into peritoneal cavity. 3. S/p right colectomy. 4. Colon cancer. 5. Anemia. I personally cleaned the abdomen and applied one-piece colostomy appliance to manage drainage. Discussed with nursing on how to apply and maintain the ostomy appliance. I left some equipment in the room and showed the patient and family as well.

In a telephone interview conducted with staff #21 NP ostomy nurse on 2/13/19 at 10:15 am, staff #21 said she saw pt #1 on 7/28/18 for consult. She said the nurses were applying towels and abdomen pads to abdominal wound. Staff #21 said she obtained the supplies, instructed the nursing staff, patient, and family how to use the ostomy supplies, left some in the room for future use.

In an interview with staff #1 at the facility on 2/13/19 in the conference room staff#1 said it looks like a communication problem.

Review of staff #24 PA and staff #25 physician, 7/30/18 1903 progress note consult for second opinion. As the patient stood up there was copious drainage from the wound. The fluid appeared to be purulent. However, there is no evidence of bilious fluid.

Review of wound assessment policy ID 81, last approved 10/2018, stated the purpose of wound assessment form is to document and track the wound characteristics and measurements on an ongoing basis. The completion of ongoing assessments can assist wound care providers in predicting and subsequently evaluating the status and or measurement of wound healing.

Review of nursing progress notes revealed wounds were assessed but there were no wound assessment forms available for the surveyor to determine if the providers reviewed the forms.

In an interview with the complainant on 2/8/19 at 11:35 am daughter of pt #1 said she sent a letter to the hospital to look into the horrific way her mother was treated. They answered back saying they were sorry the wound care team was not notified and the supplies my mother needed were not available, but they now have trained staff to notify the wound care team. She said they were making changes in the environment, looking at wound care process and supplies. But it doesn't stop my mother from having months of IV antibiotics and a wound vac.

Review of facility documentation on 2/13/19 at the hospital confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records, hospital documents and interviews with staff the facility failed to ensure the medical staff requirements were met as evidenced by the physician's failure to complete and documents a medical history and physical (H&P) examination within 24 hours after admission in 1 of 5 medical records. This resulted in the patient admitted on [DATE] received the incorrect dosage and frequency of medications on 12/06/18, 12/07/18 and 12/08/18.

The findings included:

The medical record for Patient #11 reviewed on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus revealed an H&P report dated 12/7/18 at 7:06am performed by Staff #34.

Review of the hospital Rules and Regulations of the Medical Staff dated 11/1/2018 stated in part ADMISSION OF PATIENTS 1. A medical history and physical examination shall be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. A history and physical should include the following (age specific):

Chief complaint

History of present illness

Clinically relevant past medical history

Medications

Allergies

Psychosocial history

Pertinent review of systems (may be included within the history of present illness)

Physical examination, to include at a minimum examination of the affected body area(s) or organ system(s). Blank lines on any H&P form will indicate not applicable to this patient.

An interview was conducted on the morning of 02/13/2019 with Staff #26, Patient Safety Director. When Staff #26 was asked what the hospital policy was for the completion of a medical H&P. Staff #26 stated the hospital policy was that physicians were to complete a patient's history and physical within 24 hours of admission. Staff #26 stated Staff #35 did not perform an H&P on 12/26/18 due to the physician change. Staff #26 acknowledged the H&P for Patient #11 had not been completed within 24 hours of her admission.

Based on review of patient medical records, hospital documents and interviews with staff the facility failed to ensure registered nurses supervised and evaluated the nursing care for each patient as evidenced by inadequate evaluation of patient's medical needs such as medication reconciliation, continuation of ED ordered medical therapies, and diet.

Findings were:

The medical record for Patient #11 reviewed on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus revealed nurse's notes dated 12/06/18, 12/07/18, 12/08/18 that stated the complainant, patient's daughter had called with multiple requests to speak with the Attending Physician Staff #34, with concerns about Patient #11's care plan, medications, diet, and IV fluids. IV fluids ordered in the ED dropped off after 24 hours of admission to the floor and were not reordered until 12/08/2018. A clear liquid diet was ordered in the ED on 12/05/18 due to patient's complaints of nausea and vomiting. 12/07/18 @ 0727 nurse note stated Patient had no episodes of nausea or vomiting last night. No complaints of abdominal pain.

Review of an H&P report dated 12/7/18 at 7:06am performed by Attending Physician, Staff #34. The report stated the chief complaint was nausea and vomiting. The diagnosis, Assessment & Plan were UTI, Dehydration, nausea and vomiting, Bladder calculi with a Plan of Intravenous Fluids (IVF)

A review of the hospital policy titled Medication Reconciliation with a last reviewed date of 12/2018 stated in part The purpose of Medication Reconciliation is to accurately reconcile patient medications across the continuum of care. Medication Reconciliation is an interdisciplinary process intended to enhance patient safety by reconciling current medications and decreasing the risk of adverse drug events. Medication reconciliation completed to ensure that the patient is prescribed the appropriate medications upon admission to the facility, transfer between department, and discharge from the facility. A. Medication Reconciliation is an interdisciplinary process between providers, nursing and pharmacy, of accurately collecting and reconciling a medication list for each patient. Medication Reconciliation will be completed to the best of one's ability within 24 hours of admission, 12 hours of transfer, and upon discharge.

Medication Verification: Process of confirming components of each medication the patient was taking prior to the time of admission. This includes the following elements: right drug, dose, route, frequency and date last taken. Performed by a nurse, pharmacist, or provider. The policy also noted A. Admissions 7. The second tier validation will be completed at the second point of contact for the patient. This will be done as soon as possible and within the first 24 hours of patient arrival to the hospital ... The primary nurse for the admitted patient will go through each home medication with the patient (or other reliable source).

An interview with Patient Safety Director, Staff #26 was conducted on the morning of 02/13/19 in a conference room of the Mainland Medical Center campus. When Staff #26 was asked if current staff had received additional training on medication reconciliation. Staff #26 stated the ED staff had been notified of the need for re-education related to medication reconciliation review but that there had not been any additional training of current nursing staff as of the date of the survey. She stated all new nurses are getting medication reconciliation review training in new hire orientation.

An interview with 4E Director,Staff #31 was conducted on the afternoon of 02/13/19 in a 4E unit office at the Mainland Medical Center campus. Staff#31 was asked how her RNs validate patient's home medication. She stated the nurses review home medications with the patient and/or family. The nurses also call patients' pharmacies and the pharmacist will update with the nurses. The pharmacies are the best resources. Staff #31 states the nurses perform the medication reconciliation and the physicians approve it. She stated if the physician does not return phone calls, she would call the physician and have a direct conversation with them. If she couldn't get in contact with the physician she would escalate the issue up through the chain of command.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interviews of facility staff, the facility failed to inform the patient of the patient's rights in advance of furnishing care as 2 of 7 inpatient medical records reviewed did not contain admission forms signed by the patient which include receipt of the Patient Bill of Rights which resulted in an incomplete record and the patient being uninformed regarding his patient rights.

The findings were:

Electronic medical records were reviewed on 9/25-26/18 with the assistance of the staff #2 and 3. The record of patient #7 and 10 did not contain signed admission forms which included receipt of the Patient Bill of Rights. Review of the medical records revealed that patient #7 was admitted to the intensive care unit from the emergency department on 1/2/18 and patient #10 was admitted directly to the intensive care unit on 7/25/18. The record of patient #7 contained a Conditions of Admission form that had been checked off as Patient is unable to sign and an Important Message from Medicare form signed by the husband of patient #7 on 1/16/18. The record of patient #10 admitted on [DATE] did not contain any Conditions of Admission form.

The facility policy entitled Procedure for Registration Forms and Signatures #PARA.PP.PTAC.038 dated 5/15 reflected in part The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Standard forms required at time of Pre-Registration or Registration ...2. The Conditions of Admission is obtained for all other types of Registrations (Emergency, Observation, Surgery, Inpatient and Newborn) ...3. Authorization for Release of Information. 4. Patient Bill of Rights ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign.

In an interview with the VP of Quality, staff #1 on the morning of 9/26/18, staff #1 acknowledged that the electronic medical records of patients #7 and 10 did not contain signed Conditions of Admission forms.

Based on review of documentation and interviews with facility staff, the facility failed to inform a Medicare inpatient of a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization as there was no signed Important Message from Medicare form in the medical record of patient #10.

The findings were:

Electronic medical records were reviewed on 9/25-26/18 with the assistance of the staff #2 and 3. The medical record of patient #10 did not contain an Important Message from Medicare form. Review of the medical records revealed that patient #10 was admitted directly to the intensive care unit on 7/25/18.

The facility policy entitled Procedure for Registration Forms and Signatures #PARA.PP.PTAC.038 dated 5/15 reflected in part The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Additional forms are required in the following situations: Important Message from Medicare ...if the patient is a Medicare or Managed Medicare Inpatient, it is required that the Important Message from Medicare be issued within two days of the inpatient admission ...In addition, the patient's or patient's representative's signature is required ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign.

In an interview with the VP of Quality, staff #1 on the morning of 9/26/18, staff #1 acknowledged that the electronic medical record of patient #10 did not contain a signed Important Message from Medicare form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interviews with facility staff, the facility failed to determine upon admission if 2 of 7 inpatients reviewed had formulated advanced directives as the admission forms documenting the advanced directive statements were not completed by patient #7 and 10 upon admission which resulted in an incomplete record and the facility being unaware if patient #10 had an advanced directive.

The findings were:

Electronic medical records were reviewed on 9/25-26/18 with the assistance of the staff #2 and 3. The record of patient #7 and 10 did not contain signed admission forms which included the advanced directive statements. Review of the medical records revealed that patient #7 was admitted to the intensive care unit from the emergency department on 1/2/18 and patient #10 was admitted directly to the intensive care unit on 7/25/18. The record of patient #7 contained a Conditions of Admission form that had been checked off as Patient is unable to sign and an Important Message from Medicare form signed by the husband of patient #7 on 1/16/18. The record of patient #10 admitted on [DATE] did not contain any Conditions of Admission form.

The facility policy entitled Procedure for Registration Forms and Signatures #PARA.PP.PTAC.038 dated 5/15 reflected in part The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign ...The Advanced Directives statements are contained within the Parallon standard COA (Conditions of Admission) and COS (Consent for Outpatient Services) forms ...Only one of three applicable PSDA (Patient Self Determination Act) statements is initialed or marked by the patient or legally authorized/legally empowered representative.

In an interview with the VP of Quality, staff #1 on the morning of 9/26/18, staff #1 acknowledged that the electronic medical records of patients #7 and 10 did not contain signed Conditions of Admission forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interviews of facility staff, the facility failed to inform the patient of Privacy Practices and obtain Authorization for Release of Information as 2 of 7 inpatient medical records reviewed did not contain admission forms signed by the patient which include the Authorization for Release of Information form and the Notice of Privacy Practices form which resulted in an incomplete record and the patient being uninformed of confidentiality rights.

The findings were:

Electronic medical records were reviewed on 9/25-26/18 with the assistance of the staff #2 and 3. The record of patient #7 and 10 did not contain signed admission forms which included Authorization for Release of Information and the Notice of Privacy Practices. Review of the medical records revealed that patient #7 was admitted to the intensive care unit from the emergency department on 1/2/18 and patient #10 was admitted directly to the intensive care unit on 7/25/18. The record of patient #7 contained a Conditions of Admission form that had been checked off as Patient is unable to sign and an Important Message from Medicare form signed by the husband of patient #7 on 1/16/18. The record of patient #10 admitted on [DATE] did not contain any Conditions of Admission form.

The facility policy entitled Procedure for Registration Forms and Signatures #PARA.PP.PTAC.038 dated 5/15 reflected in part The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Standard forms required at time of Pre-Registration or Registration ...2. The Conditions of Admission is obtained for all other types of Registrations (Emergency, Observation, Surgery, Inpatient and Newborn) ...3. Authorization for Release of Information. 4. Patient Bill of Rights ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign ...Procedure: Responsible Party, Patient Access. Action, Notice of Privacy Practices. The patient or legally authorized/legally empowered representative or family member initials this section to acknowledge receipt of the Notice of Privacy Practices.

In an interview with the VP of Quality, staff #1 on the morning of 9/26/18, staff #1 acknowledged that the electronic medical records of patients #7 and 10 did not contain signed Conditions of Admission forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interviews with facility staff, an ICU patient who had level 3, 1:1 monitoring and observation suicide precautions ordered had inadequate documentation in the medical record that the ordered suicide precautions were in place which was a potential patient safety issue.

The findings were:

Electronic medical record of patient #8 was reviewed with the assistance of the director of quality staff #3 on the morning of 9/26/18. The medical record reflected that patient #8 was admitted from the ER to ICU for a Benadryl overdose and had suicide precautions, L3 - 1:1 monitoring and observation, ordered on [DATE] 1031. The record contained a Suicide Patient Monitoring Form for 7/31/18 from 0700 - 1815 which documented every 15 minute observations. Facility staff were unable to find any other documentation of every 15 minute observations in the patient record. The only other documentation in the medical record related to the suicide precautions was an ER Note dated 7/30/18 1600 which reflected in part Wife and sitter are at bedside and a Multidisciplinary Team Note dated 7/31/18 0730 which reflected in part Sitter at bedside. The record contained a nurses note dated 7/31/18 2340 which reflected in part Pt (patient) D/C (discharge) to [a psychiatric facility].

The facility policy entitled Suicide Prevention Plan # 76 dated 4/16 reflected in part Heightened Observations. Patients who are at risk for suicide will be placed on patient observation and monitoring as assigned by the RN and reassessed after the QMHP (qualified mental health professional) or assigned physician assessment is completed. The patient may be placed on Standard Observation, Line of Sight, or 1:1 monitoring as outlined in the definitions below as determined by the treatment team and physician order ...Level 3 - 1:1 Monitoring and Observation. The patient is never to be out of arms reach of the assigned and dedicated staff member ...Suicide Precautions. 1. Suicide precautions are to be clearly indicated on the assignment sheet and specific patient rounds sheets, and communicated during every transition of care (change of shift, breaks and lunches) through thorough hand-off communication. 2. Staff assigned to observe patients on suicide precautions shall immediately communicate to the Charge Nurse and carefully document significant signs of concern in the progress notes ...

In an interview with the director of quality, staff #3 on the morning of 9/26/18 in a conference room, staff #3 acknowledged that there were gaps in the documentation of the ordered suicide precautions from the time of the order to the time the patient was discharged .

Based on observation, review of documentation and interviews with facility staff, the facility failed to properly store dry food and other food service supplies as boxes were stacked on the top shelves in the dry food storage room closer than 18 to the ceiling which was not in accordance with facility policy and was a potential fire hazard. A double door in the kitchen leading to the loading dock which latched in the center of the two doors had an opening to the outside approximately + x 5 in the middle of the doors where daylight could be seen from inside the kitchen providing a point of entry for insects and rodents from the outside. This had been noted in a city health department inspection 8/14/18 and had not been repaired at the time of survey.

The findings were:

During a tour of the dietary department on the afternoon of 9/24/18 in the company of the director of food service, staff #10, the following observations were made. In the dry food storage room was stainless steel shelving in rows with aisles in between. On the shelving were boxes of food products, and food service supplies which were stacked to within 6 inches of the ceiling in several places on the shelving in the center of room.

In the kitchen, a double door leading to the loading dock which latched in the center of the two doors had an opening to the outside approximately + x 5 in the middle of the doors by the latch where daylight could be seen from inside the kitchen providing a point of entry for insects and rodents from the outside.

City of Webster Food Establishment Inspection Report dated 8/14/18 reflected the facility had a demerit point for Core Item #34. No evidence of insect contamination, rodent/other animals with the remark All doors leading to the outside shall seal completely allowing no light visible from the outside.

The facility policy entitled Food and Non-Food Storage # 92 dated 1/16 reflected in part 1. Dry Storage ...c. All foods and non-foods must be stored 18 from the ceiling except for perimeter walls.

In an interview with staff #10 during the tour of the dietary department on the afternoon of 9/24/18, staff #10 acknowledged that items were stacked closer than 18 to the ceiling in the dry storage room and that there was an opening to the outside near the latch in the doors leading to the loading dock.

Based on record review and interview, the facility's direct care staff failed to promote and maintain the rights of its patients, by ensuring patients receive care and services in a safe setting free from abuse/ neglect in 2 of 10 sampled patients. Patient #s 1 and 8

Findings:

Review of the facility's current policy and procedure on Abuse/ Neglect (suspected): Elderly or dependent Adult. Policy # 95 direct facility's staff as follows:

Definition Sexual assault: Any unwanted, non -consensual sexual contact against any individuals by another.

Abuse: The willful neglect or infliction of injury, unreasonable confinement, intimidation, non- consenting sex, or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker or one's self of goods or services that are necessary to avoid physical harm, mental anguish or mental illness.

Physical Neglect: Consistent hunger, poor hygiene, inappropriate dress.

Patient #1

Review of Patient #1's clinical record, revealed a physician's order dated 03/05/2018 for admission to The Senior Care Unit at the hospital for in-patient unit with diagnosis of dementia with behavioral disorder.

Review of clips from video camera provided by Facility's Administrative staff.

Review of a series of video camera recording of incidences captured on the Senior Care Unit of the facility documented as follows:

(1) Incident recorded on 03/06/2018 at 10:15 p.m. - 10:30 p.m.: Patients #1 and a female patient, identified as Patient #8 were observed on video recording entering the media room which is located on the left of the entry way to the Senior Care unit. Both patients were utilizing rolling walkers. The female patient's walker had a seat which had a collection of paper on the seat.

After entering the media room, both patients sat on the sofa directly facing the door of the media room. The patients were seen on the video clip, hugging each other and then the male patient placed his hand on the female's thigh and caressed and kissed her thigh. The female patient #8 in return kissed the male patient's cheek. The male patient then removed his penis from his pants and placed it in the female patient's hand. The female patient then directed the male patient to give her some paper that was on the seat of her walker. She then used the paper to disguise the male patient's exposed penis. They then continued to sit on the sofa while the female patient appeared preoccupied in ensuring that the male patient's exposed penis was covered.

The male Patient #1 then stood up, pulled his pants down to his knees and exposed his penis/ genital area and buttocks. The female Patient #8 then used a blue cloth/towel to cover the male patient's exposed genital area, while they continued to kiss and her hand remained under the blue cloth/ towel covering the male patient's penis/ genital area.

At 10:28 p.m. A Male staff entered the room, identified by Facility's Administrative Staff as Registered Nurse (B). He entered the media room and had an inaudible dialogue with both patients. Registered Nurse (B) had a smile on his face while talking to both patients. The male patient then proceeded to pull his pants up from his knees, grabbed his walker and left the room behind the male nurse, while the female patient followed behind later.

(2) Incident recorded on 3/10/2018 at 8:58 p.m. - 9:13 p.m. A male individual identified by Facility's Administrative staff as Patient #1 was observed on the video recording, walking in the sitting area of the unit. The Patient was wearing a pair of paper pants with both feet in one leg of the pants. A male staff identified by Facility's Administrative Staff as Registered Nurse (F) was observed sitting in the sitting area at the computer station on wheels. The Patient approached Registered Nurse (F) and there was an inaudible exchanged of words. The Patient responded verbally (inaudible). The Patient attempted to continue walking by pushing away the nurses' hand.

Registered Nurse (F) raised his left hand and pushed Patient #1 in his chest. Registered Nurse (F) grabbed the Patient, the Patient fell to the floor.

Another male staff, identified by Facility's Administrative staff as Registered Nurse (B) approached the Patient along with Registered Nurse (F). Both registered nurses dragged the Patient along the floor, using the patient's arms, vest and shirt to drag the Patient on the floor out of site of the video. During the incident a foot of the Patient's shoes came off. The Patient did not show signs of aggression during the incident.

(3) Incident recorded on 3/10/2018 at 9:26 p.m. - 9 41 p.m.; A Male Patient identified by Facility's Administrative Staff as Patient #1 was observed on video recording walking in the sitting area of the Senior Care Unit. The Patient was wearing clothing with a large stain at his buttocks. The Patient picked up a towel and threw it in the chair, and then the Patient attempted to exit the sitting area. While exiting the sitting area, the Patient picked up a black object from a chair. The Patient swung the black object at a male staff identified by Facility's Administrative staff as Registered Nurse (B). Registered Nurse (B) forcefully pushed the patient to the floor in the sitting area of the unit. Observation revealed a foot of the Patient's black shoe on the floor. Registered Nurse (B) picked up the shoe from the floor.

Another male staff identified by Facility's Administrative Staff as Registered Nurse (F) approached the Patient who was lying on the floor. The Patient got up from the floor and Registered Nurses (B) and (F) dragged the Patient out of sight of the video. The Patient did not show sign of aggression while lying on the floor or being dragged.

(4) Incident recorded on 03/10/2018 at 10:10 p.m. - 10:25 p.m.: A Male Patient identified by Facility's Administrative Staff as Patient #1 was observed in the video recording. The Patient was sitting in a chair identified by the Facility's Chief Nursing Officer as the chair generally used by Registered Nurse (B). After sitting in the chair, the Patient was approached by a male staff identified by Facility's Administrative staff as Registered Nurse (B). Registered Nurse (B) pulled the Patient from the chair via both arm and forcefully pushed him into a Geri chair located near to the chair the Patient was sitting in. The Patient did not show any sign of aggression.

(5) Incident recorded on 03/11/2018 at 4:35 a.m. - 5:05 a.m.: A male Patient identified by Facility's Administrative Staff as Patient #1 was observed in the video recording sitting in the Geri-chair in the sitting area of the Senior Care Unit. The Patient was naked from his waist down with his pubic/ genital area exposed. The Patient's shoes were on the floor below his feet. The Patient attempted to rise from the chair, stepped on his shoes and fell to the floor. The Patient fell at 4:35 and 30 seconds. The Patient remained on the floor for 17 minutes. He was wheeled from the unit at approximately 19 minutes after falling.

During the incident a male staff identified by Facility's Administrative staff as Registered Nurse (B) was present at the nurses' station with his back to the Patient. Another individual identified by Facility's Administrative Staff as Registered Nurse (F) was sitting in the nurses' station. Registered Nurse (B) walked up to Patient #1 who was lying on the floor with a pool of red substance near his head, gave a cursory look at the Patient, stepped over the Patient's body on the floor, then walked away. This red substance was identified as Frank blood noted on the floor near the Patient's head.

A female individual identified as Charge Nurse (G) walked over to the Patient, bent over the Patient, touched the Patient and walked back to the nurses' station. The Patient remained on the floor with the red substance near his head.

A male nurse identified as Registered Nurse (F) picked up a towel and proceeded to wipe the blood from the floor with his foot. The nurse's foot used to wipe the blood from the floor was in close proximity to the Patient's face who was on the floor.

He then returned to the computer on wheels, sat down and proceeded to write. The Patient remained lying on the floor unattended by facility's staff.

Registered Nurse (B) with his back to the Patient reviewed records while the Patient remained on the floor. The Patient attempted to get up from the floor unattended. The Patient remained on the floor for approximately 17 minutes.

Observation of the video recording revealed, there was no assessment, neurological assessment, or emergency care provided to the Patient lying on the floor with his head in a pool of blood.

After approximately 17 recorded minutes, the Patient was placed in a wheelchair and rolled from the unit. The Patient left the unit for the emergency room after approximately 19 minutes.

Review of a physician's progress notes (Emergency Provider Report) dated 03/11/2018 at 0546 revealed the following documentation; 76 yr male presents to the ED from Senior Care at this hospital c/o forehead laceration s/P fall today. fell out of chair and hit forehead on floor. No LOC, per triage notes. Trauma general: Laceration (3 cm gaping wound, Lt forehead.)

0602 Location of wound: left forehead. Wound Length: (cm) 3. Sutures 6.

Review of a Fall Audit Post Fall Debrief Record, dated 3/11/2018, revealed the following documentation: Pt was encouraged to go to bed numerous times but refused. fell asleep in the day area. Tried to get up while he was drowsy and fell . Laceration to head stitched.

Interview with Facility's Chief Nursing Officer

Interview with the Facility's Chief Nursing Officer on 03/27/2018 at 9:10 a.m. revealed the Senior Care Unit is currently closed in relationship to a pattern of incidences which happened on March 6th, 10th and 11th 2018. She said Patient #1's family informed the facility that the Patient alleged that he was pushed by a staff and sustained a cut to his face. She said while doing the investigation and reviewing video clips, the facility discovered a pattern of abuse neglect of patients on the unit by facility's staff. Monitoring of the unit with outside staff was implemented and a report was made to the Licensing agency.

She said the incident of patient to patient sexual abuse was brought to the facility's attention on March 22, 2018 and a decision was made to cease admissions to the unit. Patients who could be discharged , were discharged to home and other patients were transferred to various facilities in the community. She said the unit is currently under renovation focusing on the door knobs which are ligature risks and some cosmetic renovation.

She said the facility's administrative staff are currently evaluating processes and policies in the operation of the unit along with staff training. She said as a result of the investigation, three staff member were terminated and retraining of all staff have begun. The staff terminated were referred to the Board of Nursing. Patient #1 was transferred to a sister facility.

Interviewed Units Intake Coordinator

Interview on 03/27/2018 with the Unit's Intake Coordinator(I) revealed, Patient #8 was a caretaker who attempted to go from patient to patient to check on them. As a result, the Patient had to be redirected constantly.

He said Patient #1 was manic with poor boundaries. He said both patients had no history of sexually acting out. He said the facility was not made aware of the incident until after the female patient was discharged . He said Patient #1 was admitted to the unit on March 5th, the incident happened on March 6th and the Female Patient was discharged from the facility on March 7, 2018.

Interviewed Registered Nurse (A)

Interview on 03/27/2018 at 11:41 a.m. with Registered Nurse (A) in the presence of Facility's Chief Nursing Officer revealed, on the night of March 6, 2018 while going to the bathroom, she saw two patients in the media room of the Senior Care Unit. The male patient was sitting on the sofa while the female patient was standing.

On returning from the bathroom, she saw both patients sitting on the sofa close together. She stated It seems they were getting too friendly. She said she went back to the nurses' station and reported what she saw to Registered Nurse (B), one of the nurses on the unit.

She said she had never observed any of the patients sexually acting out. She said Patient #8 was a caregiver, in the past was a preacher who liked to take care of others. She said at times when the media room is opened patients are allowed to go in and listen to the radio or read a book.

Interviewed Registered Nurse (B)

During an interview via the telephone with Registered Nurse (B) on 03/27/2018 at 12:00 noon, revealed he said, on the night of March 6, 2018 Patient #1 was in a room with a Lady Patient (Patient #8). He said he was not assigned to the Lady Patient. He said the patients were sitting down with their arms around each other. He told them they could not do that.

He said he saw Patient #1 with a towel on his lap, and asked the Patient What's going on with that towel. He picked up the towel and noticed that the Patient's pants were down to his knees. He said he directed them out of the room.,

Registered Nurse (B) said he saw when both patients entered the media room, that they were there for approximately 4 minutes and that he was giving them a chance. He said he had gone in to check on them, when he witnessed the incident. He said he reported the incident to the staff on the unit but he could not recall who was the Charge Nurse.

When asked if he had completed an incident report, he said he did not make out one because nothing happened. He stated Whatever they were going to do I stopped it.

He said there was another incident with Patient #1 on March 11th where the Patient got up out of his chair and fell . He stated I tried to catch him from falling but I could not. He said the Patient had blood on his hands and that was when he noticed that the Patient had a cut on his head.

Interviewed Unit Manager (H)

Interview with Senior Care Nursing Manager (H) revealed he was made aware of the incident on March 22, 2018. Patient #1 was transferred to a sister hospital.

He said the nurses reported that Patient #1 tried to grab at the nurses. He said the Patient stayed in the day area most of the time when he was not sleeping.

Interviewed Registered Nurse (M)

Interview on 03/28/2017 at 8:00 a.m. with Registered Nurse (M) revealed, she has been working in the facility for approximately 7 months under the Star New Graduate Program. She said she did receive training on abuse neglect.

She said on the night of the incident on 03/06/2018 she could not recall if she was assigned to Patient#1.

The Surveyor then reviewed the 15 Minutes Rounding Sheet which showed her signature monitoring the patient on the night of the incident.

She said she did not see the patients in the media room but Registered Nurse (B) told her that he saw the male patient with another female patient and they were trying to touch each other. He immediately took them from the media room. Registered Nurse (B) took the female Patient#8 and she took the male Patient #1 to his room.

The Surveyor then reviewed the 15 Minutes Rounding Sheet with Registered Nurse (M). The Surveyor informed her that she had documented that she had rounded on the patient at 22:15 that the Patient was in the media room sitting at 22:15. She said there was no area on the monitoring sheet for media room and that was the reason why she documented day room.

She said, the practice on the unit is to trade hours, i.e. one nurse round on the patients every 15 minutes for one hour intervals, and the nurse assign to the patients document on the rounding sheet although the nurse did not actually see the patients. The Fifteen Minutes Rounding sheet is not shared with each other.

She stated That's how I was trained. I never knew better.

Interviewed Registered Nurse (F)

On 03/28/2018 at 8:48 a.m. the Surveyor received a telephone call from a female who identified herself as a lawyer representing Registered Nurse (F) who wanted to be on the telephone call during the interview with her client.

The Surveyor informed her that during an investigation by Agency Personnel, lawyers are not accommodated. She then notified the Surveyor that her client would be calling the Surveyor.

Interview on 03/28/2018 at 8:52 a.m. with Registered Nurse (F) via the telephone revealed, the Surveyor asked the Registered Nurse if they were the only two individuals on the telephone. Registered Nurse (F) Informed the Surveyor that the interview was between the Surveyor and the Registered Nurse and there was no other party on the telephone.

Registered Nurse (F) stated I came back from Florida. I wasn't assigned to Patient #1 but I helped Registered Nurse (B), the nurse who was assigned to him. The Patient was sitting in a chair, he was aggressive earlier on and refused to follow orders. I helped Registered Nurse (B) to change him in his room and he gave him medication to calm him down. He removed his underpants and came out without the bottom. He sat in the chair and fell asleep in the chair. We did not want to wake him because the medication had taken effect.

Later in the morning I was sitting behind the desk at the nurses' station and Registered Nurse (B) was standing in front of the desk. I saw him look around. I asked Registered Nurse (B) what happen? He said The gentleman had fell . I asked him if he was ok. Registered nurse (B) told me I think he hit his eye and there was blood.

I came out of the room and Registered Nurse (B) went to get the Charge Nurse. The Charge Nurse came and assessed the Patient. I stayed with the Patient while the Charge Nurse and Registered Nurse (B) went to get a wheelchair and vital signs monitor. They only came back with only the wheelchair. Nobody did vital signs on the Patient. I put a towel on a small amount of blood on the floor.

I tried to do my best at all times. I have never abused or witness abuse on any patients. I have pulled patients by the hands because he was resistant. No one was trying to abuse the patient. I was shown video of the Patient on the floor and me standing there. He was taken to the ER I don't know how many sutures he received.

The Surveyor then asked Registered (F) if he was able to see if the Patient was still bleeding while he was lying on the floor. He stated that he was able to visualize the cut on the Patient's face and that the bleeding did not persist although staff did not arrest the bleeding.

Interviewed Licensed Vocational Nurse (P)

Interview on 03/28/2018 at 9:30 a.m with Licensed Vocational Nurse (P) in the presence of Facility's Chief Nursing Officer revealed, she has been working at the facility for approximately 6 months.

She said Patient #1 was sometimes sexually inappropriate. She said on one occasion the Patient was sitting in a Geri-chair, he remarked that he had a chair like the one he was sitting in at home and implied what he would do to her.

She said she cannot recall any patient to patient sexual abuse, but could recall another Patient trying to kiss and hug another female patient. She said the patient had to be redirected and kept them apart.

Based on record review and interview, the facility's registered nurse failed to supervise the care of patients in 2 of 10 sampled patient. Patient # 1 and 8

Patient #1

Review of Patient #1's clinical record (Fifteen Minutes Rounding Sheet) dated 03/06/2018 revealed documentation which indicated that the Patient was in the day room at 2215 and 22:30.

The Fifteen Minutes Rounding Sheet also indicated that Patient #1 was monitored by Registered Nurse (M) for the entire night.

The Surveyor then reviewed the 15 Minutes Rounding Sheet with Registered Nurse (M). The Surveyor informed her that she had documented that she had rounded on the Patient at 22:15 that the patient was in the media room sitting at 22:15.

She said there was no area on the monitoring sheet for media room and that was the reason why she documented day room.

She said, the practice on the unit is to trade hours, i.e. one nurse round on the Patient every 15 minutes for one hour intervals, and the nurse assign to the patient document on the Fifteen Minutes Rounding Sheet, although the nurse did not actually see the patients. She said the Fifteen Minutes Rounding Sheet is not shared with each other.

She stated That's how I was trained. I never knew better.

Patient #1

Review of Patient #1's clinical record (Fifteen Minutes Rounding Sheet) dated 03/11/2018 indicated that the Patient was monitored by Registered Nurse (B) in the following environment:

04:30, 04:45, 05:00, In room with staff sleeping and breathing.

05:15, 05: 30: In room with staff toileting.

05:45, 06:00, 06:15, 06:30, 06:45: In room with staff.

However, Review of the Patient's emergency room Provider Report dated 03/11/2018 documented that Patient #1 was in the emergency room at the following times.

0509: Point of Care Testing, Temperature, Pulse, Respiration, blood pressure and pulse Ox performed in the emergency department.

0602: Patient wound to left forehead sutured.

0630: Patient at radiology - XR pelvis + views.

0638: Patient at CAT Scan.

Registered Nurse (B) documented that he was supervising the care of Patient # 1, while the Patient was off the Senior Care Unit to the emergency room for treatment, for a laceration he obtained when he fell on the Senior Care Unit.

Patient # 8

Review of Patient #8's, Fifteen Minutes Rounding Sheet dated 03/6/2018 revealed documentation which indicated that the Patient was monitored by Registered Nurse (B) at 22:15, 22:30, 22:45 as being in the day room.

Review of a Video Clip provided by Facility's Administrative Staff revealed the Patient was in the Media room of the facility with Patient #1.

Based on interviews and record review the facility failed to adhere to its grievance policy for 1 out of 1 patient #4 with documented grievances.

Findings: Facility failed to provide evidence of investigation and post investigation letter per policy to patient #4 who complained that a nurse had entered her room wearing a fragrance triggering a Trigeminal nueralgia event.

Tx 532

Interview on 10/4/2017 with Director of Quality, ID #57 at 1:00 PM was asked if certified letters are sent to patient's to follow up with complaints, she responded, yes. Director ID #57 when asked to provide the letter for patient #4, was unable to locate the post-investigation written response to the above complainant's grievance.

Interview on 10/4/2017 with Risk Managemant Manager ID #58 at 1:30 PM reported that all grievance should be documented in the log, and a follow up letters should have been documented. Letters are sent certified requiring the recipeant did receive the letter. It is not acceptable that no documentation can be located on the compalint/grievance form for patient ID #4.

Interview on 10/4/17 with Nurse Manager #55 at 10:00 AM when asked if she was aware of the event on 1/30/17 involving patient ID #4 she said yes. Asked if an incident report had been written and her complaint received? She said, I did not write an incident report. As for the complaint, Risk Management #60 spoke with the patient #4.

Interview with RN, CNO, #61 at 2:30 PM reported that it is not acceptable that no documentation could be located involving the incident with patient #4. Yes, the expectation is all incidents and or complaints are communicated and report written.

Record review on 10/04/17 of facility policy titled: Risk Management-Notification of Occurrences reads:

1. It is the policy of the The Clear Lake Regional Medical Center that all incidents occurring at the hospital involving employees, patients, visitors, or property must be reported utilizing the Meditech online Notification Report.

2. While the responsibility for occurrence report and investigation exisits at all levels of hospital management, the primary burden of responsibilty is placed on the immediate supervisor in whose area an incident occurred.

Record review on 10/04/2017 of facility policy titled Grievance and Complaint Management, dated 04/2016, read

... 2. ...appropriate department director/manager will be contacted to review, investigate, and resolve with the patient and/or patient representative, with the goal of resolution to be wihtin seven (7) days of receipt of the grievance.

3. ...if the investigation is not or will not be compleed within seven days (7) days, the complaintant should be informed that the facility is still working to resolve the grievance and that the facility will folloe-up with a written response within twenty-one (21) days.

4. In resolution of the grievance a written notice of the decision MUST be provided to the complainant which should contain the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and records reviewed the facility failed to uphold 1 of 1 patient right to safe setting.

Facility failed to document and investigate a known environmental exposure that resulted in patient #4.

Findings include:

TX 532

Record review of complaint intake # TX 532 revealed patient #4 stated, she requested staff not wear fragrance when providing care as this exacerbates her [DIAGNOSES REDACTED]. She went on to say staff wore fragrance ignoring her request and a [DIAGNOSES REDACTED] event occurred.

Interview on 10/4/17 with Nurse Manager ID# 55 at 10:00 when asked if she was aware of the event on 1/30/17 involving patient ID #4 she said yes. As a Nurse Manager, is it expected that all incidents on your Unit are to be written up, yes.

Interview on 10/4/2017 with RN, ID # 54 at 10:15 AM reported he remembered patient #4 and cared for her on day of the tirgrminal event. Nurse # 54 further reported he had called to Oncology Unit to have a nurse come to Unit 5 to address patient's Port-A-Cath. Asked, was a sign on the door stating No fragrances, he said, yes. Nurse #54 reported that night patient#4 could not speak and her lower chin was quivering and shaking after the nurse from Unit 6 had been in the room. She requested I call her Neurologist by sending me a text and I did.

Record review on 10/04/17 of faciulity policy titled: Patient Rights and Responsiblities, dated 04/2016 revealed the following:

12. ...The patient has the right to security and to receive care in a safe setting

a. The patient has the right to expect reasonable safety insofar as the Hospital practices and environment are concerned.

Record review on 10/4/17 of policy titled: Dress Code, dated 01/2016 revealed the following:

GUIDELINES FOR APPROPRIATE DRESS

(6) ... Colognes/Perfume: Employees should apply perfume and /or cologne lightly- if at all- to ensure co-workers and customers who have fragrance sensitivity are not affected. Employees in departments and/or areas of the hospital that are known to have co-workers with adverse reactions to fragrances are NOT ALLOWED to apply perfume and/or cologne before or during working hours this includes perfumed soaps and lotions.

Based on observation, record review, and interview, the facility failed to ensure that patients recieve care in a safe setting.

A patient was diagnosed with acute psychosis and deemed to be a substantial risk of serious harm to self or others but was not placed on a 1:1 observation;

The facility failed to have systems in place to effectively monitor a sedated psychiatric patient in the emergency room (ER)to ensure the patient's safety was maintained;

The patient was able to leave his room in the ER undetected.

The facility failed to ensure surveillance camera used in patient's room as an observation device, was positioned to visualize the patient's room;

The cameras were not seeing activities in patient rooms with surveillance cameras.

The facility failed to ensure a patient in the ER on suicide precautions was monitored every 15 minutes according to their Standard of Care for Behavioral Health Patient in the Emergency Department policy/procedure dated September 2016.

This failed practice lead to the patient's escape from his room in the ER, went outside, carjacked a visitor's vehicle, drove away from the facility, ran a red light causing a fatal crash, killing one person and seriously injuring himself. Citing one (1) patient named in a complaint (Patient #1).

Ref to A 144 ( 482.13 (c )(2) for details.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and interview, the facility failed to ensure that patients recieve care in a safe setting.

The patient was diagnosed with acute psychosis and deemed to be a substantial risk of serious harm to self or others but was not placed on a 1:1 observation;

The facility failed to have systems in place to effectively monitor a sedated psychiatric patient in the emergency room (ER) to ensure the patient's safety was maintained;

The patient was able to leave his room in the ER undetected.

The facility failed to ensure surveillance camera used in patient's room as an observation device, was positioned to visualize the patient's room;

The cameras were not seeing activities in patient rooms with surveillance cameras.

The facility failed to ensure a patient in the ER on suicide precautions was monitored every 15 minutes according to their Standard of Care for Behavioral Health Patient in the Emergency Department policy/procedure dated September 2016.

This failed practice lead to the patient's escape from his room in the ER, went outside, car jacked a visitor's vehicle, drove away from the facility, ran a red light causing a fatal crash, killing one person and seriously injuring himself. Citing one (1) patient named in a complaint Patient (#1).

Findings:

Facility Policy Review

Review of the facility's Policy titled Standards of Care for the Behavior Health Patient in the emergency room dated September 2016, revealed the following information:

If the ED Physician determines that the patient cannot safely be released from the hospital because of an emergency psychiatric condition in which the patient presents a danger to him/her self or to others, or is gravely disabled [unable to provide for his or her basic personal needs, of food, clothing, or shelter],

The ED Physician may involuntarily detain the patient for assessment by the BH clinician in accordance with (State and or Local) Mental Health Laws.

The ED Physician will document this assessment in the medical record, including the reason[s] that the patient cannot safely released from the hospital and the time involuntary detention began.

The patient will be assessed for degree of physical impairment and behavioral changes such as confusion, disorientation, anger, depression, and verbalized intent for suicide and/or elopement.

Staff will utilize the Hospital Suicide Risk Screening and Behavioral Close Observation/ Sitter Policy for patients identified with suicide risk.

The staff observation of the patient's location, activities, and behavior will be documented on the patient's Observation Record every 15 minutes. Each observation is charted as performed by the person assigned, assuring the accuracy of documentation at all times.

Due to the duration awaiting Psychiatric Hospital placement, care activity may also include support for showering, meals and toileting.

All staff will be vigilant in regard to changes in patient behavior and will report to the nurse immediately.

Medical Record Review Patient (# 1)

Review of emergency room record revealed a [AGE] year old individual (Patient # 1) arrived at the emergency room (ER) on 6/4/2017 at 18:22 accompanied by his wife. His wife gave history the patient had altered mental status, aggressive and the family was concerned with his behavior. He was triaged as Emergent.

Review of nurses' assessment notes dated 6/4/2017 at 18:27 revealed documentation there were no verbal or physical threats from the patient. He was irritable and confused.

Violent/aggression Assessment Checklist (VAAC) was completed scoring risk type of two (2) moderate at 19:12.

There was documentation that the patient required moderate intervention which included:

Precaution rounds every 15 minutes,

applicable non-crisis intervention,

observe for escalating behaviors during interactions.

Notify Charge Nurse of any marked escalation in behavior. Spouse at bedside.

The patient denied suicidal or homicidal ideation.

There was documentation that the patient's wife was educated on safety, medication and was encouraged to give input and participate.

Vital sign Pulse 120, Respiration 17, Blood Pressure 147/76, oxygenation on room air 99%.

Review of ER physician notes dated 6/4/2017 at 18:46 revealed the following information:

Twenty six (26) year old presents to the ER with wife for paranoia and aggressive behavior since yesterday (6/3/2017.

Patient's wife said, she took the patient to Hospital (S 77) yesterday for chest pain and headache, onset two weeks ago.

The wife said the patient started to act bizarre so a psych evaluation was done at Hospital S 77 and the patient was given Ativan.

The patient was evaluated at a Health Center for bizarre behavior today (6/4/2017) and now the wife states the patient is convinced his medications are being tampered with.

The wife reported he had not been eating and he smoked marijuana last weekend. He had a history of Hypertension.

The history was limited due to AMS and uncooperativeness. The Patient was becoming more agitated, paranoid, combative, and aggressive at home. Not sleeping or eating for days, history of mental illness in family, wife states he does not drink, he smokes marijuana but no other drugs.

Risk Stratification: Suicide

Altered mental status and uncooperativeness.

Clinical Impression: Acute psychosis.

Secondary Impression: Dehydration, Delusion, Hypertension, Hyponatremia, Insomnia, Marijuana abuse, paranoia Tachycardia.

Review of Physician orders dated 6/4/2017 at 18:43 were as follows laboratory tests for comprehensive metabolic panel (CMP),

Drug screen, complete blood count (CBC).

Suicide Precautions,

Geodon 10 mg, IM, EKG,

Benadryl 25 mg.

Cardiac Enzyme Profile, Troponin, Sodium Chloride IV.

Review of Medical record for Patient (#1) revealed an Emergency Detention Order dated 6/4/2017 at 19:07 with the following information:

(2). I have reason to believe and do believe that the above named person evidences a substantial risk of serious harm to himself/herself or others Based upon the following:

Subjects statements and actions towards others. Subject has been aggressive with family and believes T. V is talking to him. This information was reported to me by Dr. (Q64).

The statement was signed by a Peace Officer( R 76).

The physician documented on the Detention Order that Patient (#1) was evaluated on 6/4/2017 at 1900 PM which was within the 24 hours of the time the person was apprehended. On the basis of the preliminary examination I am of the opinion:He/She is mentally ill, the nature of which the disorder is as follows:

The physician described the disorder as He/She evidence a substantial risk of serious harm to self or others, which is described as follows:

Patient with insomnia for three (3) days, aggressive with family, delusional, hallucination.

This information was signed and dated by the examining physician,( Physician Q64).

Review of medication administration record revealed on 6/4/2017 Patient (# 1) was administered Geodon 10 mg intramuscularly in left arm at 19:08.

There was documentation that most common side effect of the medication was drowsiness and weight gain and was reviewed with the patient.

Benadryl 25 mg was also administered at 19:08 in left arm. Common effects of the medication was documented as drowsiness, dizziness and fatigue and was discussed with the patient.

There was documentation the Benadryl was not administered for an adverse drug reaction.

At 21:15 there was a behavior health related assessment documented as no change this activity was recorded at 22:46.

At 22:15 there was nursing documentation as follows: Suicide Precautions.

Eloped, AMA, left to home unaccompanied ambulatory via private vehicle.

Medical Record for Patient (# 1) Hospital T 78(after the crash)

Review of emergency room record from Hospital T 78 revealed the following information:

The patient arrived at the hospital's ER on 6/4/2017 at 22:56 via EMS with reason for visit as motor vehicle accident unknown speed and loss of consciousness. He rear ended another car and both cars went up in flames.

The patient sustained Liver laceration, Nasal Bone Fracture, Subarachnoid Hemorrhage and 6% TBSA(Total Body Surface Area) 2nd degree burns, Rib

Fracture, Pulmonary Contusion and essential Hypertension. He was admitted to the Intensive Care Unit (ICU) for continued care. He was discharged from the hospital on [DATE] into Police to a State Correctional Facility.

Review of Emergency Department (ED) Surveillance Video Recording

Review of the ED video #1 from 6/4/2017 revealed 1813 Patient (# 1), enters the ED with his wife and appears reluctant to enter.

Video #2- on 6/4/2017 at 1829 the patient was taken to room 4, accompanied by wife and was in the room for approximately three(3) hours .

Video #3 on 6/4/2017 at 2140 the patient's wife left the room.

The unit secretary at the nurses station is on the phone. Three(3) people at the nurses station.

At 21:55 six (6) people are at the desk at the nurses station, the unit secretary/monitor Technician is busy. The patient is undetected until he walks by the nurses station.

Staff # B 52, RN Charge Nurse identifies the patient and verbally confronts the patient who did not stop walking. She follows him out of the ED. The patient did not appear aggressive.

Video # 4- (Alternative camera angle) on 6/4/207 at 21:57 the Patient (#1) reaches the main ED doors and attempts to leave the ED, realizing the door is locked, he turns around and left through a side exit door.

Charge nurse walking behind the patient speaking on her phone. None of the other staff attempted to intervene. Both nurse and patient exited the Emergency Department.

Video #5- (Exterior view of the parking lot towards the ambulance bay) on 6/4/2017 at 21:58 Patient # 1 tried the door to a car it is locked.

Video #6 and 7- Exterior view facing ED parking lot. At 21:58 shows black Lexus in process of exiting the parking lot, two nurses watching and vehicle occupants in the vacated parking spot. An individual was lying on the ground being assisted by the nurse. The car sped away.

Observation in the emergency room

Observation rounds in emergency room on [DATE] between the hours of 0900 and 11:32 am revealed there were adequate staff for a 23-bed emergency department (ED).

Room two (2) located near the nurses station had two beds and this room is dedicated for patients with a psychiatric problems.

Rooms three (3) and four(4) also located close to the nurses station are used for patients with psychiatric problems when room two is full.

The three(3) rooms had a sign on the rooms which state these rooms are monitored by surveillance cameras at all times. There was a video monitor located on the desk at the Nurses station.

During an interview on 6/8/2017 at 9:45 am with Staff D 54, RN Director of the emergency room , she stated the video monitoring is done by the Unit Secretary or Charge Nurse and if they are not at the desk any staff can monitor.

The Surveyor asked Staff D 54 why was the Patient (#1) able to leave his room without being detected when there were cameras located in the rooms? she stated the cameras were not positioned so they could see into the rooms.

She further stated the patient did not have a sitter, his wife who was in the room with him had left to get food and did not tell staff she was leaving.

She stated the 15 minute monitoring was not done.

During a telephone interview on 6/8/2017 at 9:30 PM with Staff B 52, Charge Nurse on duty when Patient (# 1) eloped, she stated usually she was not assigned patients but on 6/4/2017 there were two other patients with psychiatric problems in the ER.

She stated the Primary Care Nurse assigned to Patient(#1) was attending to a patient with trauma condition so she had to take over four patients and also assisted him with the trauma case. Staff B52 stated it was difficult to monitor psych patients and see to all the other patients in the ER.

She stated she realized the patient had left his room when he was walking past the nurses station. She tried to encourage him to return to his room but he kept going.

She was following him to see if he would stop. He only spoke to her once saying get the hell out of my way when he reached the exit door which lead to the passage way leading to the ambulance entrance she called security, however, as they passed by the security station she heard the phone ringing in the station and realized security was not in there so she called the operator for security.

According to Staff D 54, she did not call a Code Gray(used for aggressive patients) because the patient was not aggressive. She followed him out into the parking lot and by the time security arrived, the patient had carjacked a car from some visitors and drove away from the facility.

Within a few minutes he ran into an oncoming car causing an accident which killed the other driver and he sustained severe burns and was taken to a Trauma 1 emergency room for care.

During an interview on 6/8/2017 at 11:50 am with Staff H58, hospital Security Manager he stated when he received the call on his radio that he was needed in the ER he was there within two(2) minutes. He stated ER staff initially were not aware why he was called and he did not see any activities in the ER that required his attention.

He went outside but did not see anything, it was only when he went back into the ER that a staff told him Staff B 52 was gone after a patient. When he went outside he was just in time to see the patient reversed a car hitting down a lady, then driving away from the parking lot.

Before he could call 911, there was the sound of sirens and police and ambulance speeding by. He later went to the scene and saw a fiery crash.

Staff H58 stated a Code Gray should have been called initially. Usually when a Code Gray is called several persons would respond. He stated staffing was limited. Only two security personnel to serve the entire hospital during the day and one at nights. He was responding to another call when security was initially called.

During an interview on 6/9/2017 at 9:15 am with the Chief Nursing Officer she stated going forward family members will not have the sole responsibility to monitor patients in the ER.

She stated all staff present in the ER including physicians were educated and were given an opportunity to participate in the root Cause analysis.

Based on observation, record review, and interview the facility failed to maintain an effective system to control infection. The facility failed to maintain cleanliness in 11 out of 11 exam rooms, (#1,#2,#5,#7,#17,#20,#21,#22,#23,#24,#25) in the emergency department.

Findings include:

Observation on 2/28/2017 at 9:05 am in the emergency department (ED) revealed heavy dust on top of the cardiac monitors and wall mounted call lights in rooms #1, #2, #5, #7, #17. #20, #21, #22, #23 #24, #25.

Dirt noted on the wheels of stretchers in room #17

Heavy stains on cloth chairs noted in room #1, #17

Rust noted on ceiling vents and stains noted on the floor in trauma room

Equipment dusty and dirty on rolling computer used for face-to-face with psychiatrist

Dusty with dirty bases - Portable otoscope and (2) portable suture lights

Base of intravenous (IV) poles dirty and stained

Heavy dust on wall vent of visitor bathrooms

Stained floor- visitor bathroom

Dirty gauze noted on the floor of the Psychiatry evaluation room

Dirty sink near room #20

Interview with ED Manager ID# 58, on 2/28/2017 at 9:00 a.m. stated there was no set cleaning schedule for the emergency department, and nursing staff are required to clean the area between patients. She also stated they see 100-120 patients per day.

Interview with Director of Environmental Care, (EVS) ID # 57 on 2/28/2017 at 11:45 a.m. stated that environmental care was responsible for cleaning the bedside tables, floors, wiping the cardiac monitors, and nurses are responsible for cleaning the stretchers, mattresses, and pulling the trash. One person is assigned per eight hour shifts. The environmental staff are not responsible for cleaning or dusting anything with wheels. The curtains are changed once a quarter, unless the patient is on contact isolation. We only mop the floor since they are wood. This building is old but we can keep it clean. The last time the ED was terminally cleaned was December.

Record review of policy Cleaning the emergency room dated 4/2013 stated the EVS tech will scrub and wax the floor in each patient's room as needed, and change the curtain.

EVS staff will high dust the halls, waiting areas, nursing station and rooms

EVS is responsible for cleaning stretches,

Lights, vents, sinks, procedure stands

Based on interview and record review, the facility failed to ensure adequate numbers of registered nurses (RN) and other personnel to provide nursing care to patients in the neonatal intensive care unit (NICU) during the months of June, July, and August 2015.

The facility failed to provide adequate nursing staffing in the NICU :

8 of 30 days in June 2015

13 of 31 days in July 2015

7 of 31 days in August 2015

Findings include:

TX 969

Record review of complaint intake # TX 969 (anonymous letter dated August, 2015) read: ..the NICU..has been working with dangerously low numbers of RNs for many months...In house 'Safe Harbor' has been called multiple time by numerous shifts...no measures put forth to correct...Many times, the nurses in Level II have 5 sometimes 6 patients...

Interview on 11-18-15 at 9:15 a.m. with NICU Director # 13 she stated staffing was as follows : Level II acuity babies: maximum assignment for 1 nurse was four(4) Level II patients. Acuity level III babies were more critical (on ventilators, pressor drugs, etc) maximum assignment per nurse was two(2) Level III patients. NICU Director # 13 went on to say the facility based its staffing on AWHONN guidelines (Association of Women's Health, Obstetric and Neonatal Nurses).

Record review of NICU staffing assignments; patient census and acuity ( day and night shifts) were reviewed for the months of June, July, and August, 2015. These same records were discussed and verified with NICU Director # 13 and Charge Nurse # 10.

Based on this review, the following staffing deficits were identified:

JUNE 2015: LEVEL III babies ( maximum 2 patients):

Day shift:

*Three (3) nurses were assigned three (3) Level III babies on 06/20/15 and 06/21/15,

*Two (2) nurses were assigned three (3) Level III babies on 6/26/15.

*One (1) nurse was assigned three (3) Level III babies on 6/19/15 and 06/27/15.

Night shift:

* Two(2) nurses were assigned three (3) Level III babies on 6/28/15 and 6/29/15.

*One (1) nurse was assigned three (3) Level III babies on and 06/14/15.

JUNE 2015 LEVEL II babies ( maximum 4 patients):

Day shift:

*Three (3) nurses assigned five (5) Level II babies on 6/21/15 ; one (1) nurses was assigned six(6) level II babies that same day.

* One (1) nurse was assigned five(5) Level II babies on 06/15/15 and 06/20/15.

Night shift:

*Three (3) nurses assigned five (5) Level II babies on 6/29/15

One (1) nurse was assigned five(5) Level II babies on 06/14/15 and 06/20/15.

JULY 2015: LEVEL III babies ( maximum 2 patients):

Day shift:

*Three (3) nurses were assigned three (3) Level III babies on 07/01/15,

*Two (2) nurses were assigned three (3) Level III babies on 07/05/15 and 07/25/15**.

*One (1) nurse was assigned three (3) Level III babies on 07/03/15; 07/04/15; 07/06/15; and 07/19/15.

** Of note, on 07/25/15: charge nurse and transport nurse were each assigned two (2) Level III babies. Interview with Charge Nurse # 10 on 11-18-15 at 10:15 a.m., she said had either the charge nurse or transport nurse been needed for critical duties/needs on 07/25/15 ; their patients would have been assigned to nurses already caring for an over maximum patient load.

Night shift:

* Two(2) nurses were assigned three (3) Level III babies on 7/15/15 and 07/26/15.

*One (1) nurse was assigned three (3) Level III babies on 07/02/15; 07/04/15; 07/05/15; 07/06/15; 07/17/15; 07/29/15; and 07/23/15.

JULY 2015: LEVEL II babies ( maximum 4 patients):

Day shift:

*Two nurses were assigned six (6) Level II babies on 07/25/15 ;two(2) nurses were assigned five (5) level II babies that same day.

* Two(2) nurses were assigned five(5) Level II babies ; one (1) nurse was assigned six(6) Level II babies on 07/01/15.

*Two (2) nurses were assigned five(5) level II babies on 07/02/15 and 07/03/15.

*One (1) nurse was assigned five (5) Level II babies on 07/19/15 and 07/20/15

Night shift:

*Four (4) nurses were assigned five (5) Level II babies on 7/23/15.

*Two (2) nurses were assigned five(5) Level II babies on 07/06/15 and 07/22/15.

*One (1) nurse was assigned five (5) Level II babies on 07/19/15 and 07/26/15.

AUGUST 2015: LEVEL III babies ( maximum 2 patients):

Day shift:

*Three (3) nurses were assigned three (3) Level III babies on 08/15/15 and 08/16/15.

*Two (2) nurses were assigned three (3) Level III babies on 08/21/15.

*One (1) nurse was assigned three (3) Level III babies on 08/06/15.

Night shift:

*Three (3) nurses were assigned three (3) Level III babies on 08/06/15.

*Two(2) nurses were assigned three (3) Level III babies on 08/07/15; 08//24/15; and 08/25/15.

*One (1) nurse was assigned three (3) Level III babies on 08/09/15; 08/10/15; 08/11/15; 08/12/15; 08/20/15; and 08/23/15.

AUGUST 2015: LEVEL II babies ( maximum 4 patients):

Day shift:

*Three (3) nurses were assigned five(5) Level II babies on 08/15/15 and 08/21/15.

*One (1) nurse was assigned five (5) Level II babies on 08/16/15.

Night shift:

*Three (3) nurses were assigned five (5) Level II babies on 08/24/15 and 08/25/15.

*Two (2) nurses were assigned five(5) Level II babies on 08/07/15 and 08/20/15.

_____________________________

On 11-17-15, between 9:45 a.m. and 2 p.m., nine (9) NICU registered nurses were interviewed ( Staff # 4, 5, 6, 7, 8, 9, 10, 11, 12). Interviews revealed the following:

1. All nine (9) RN's stated the NICU was short staffed for both shifts during the summer. Several RNs gave exampled of unsafe staffing situations:

RN # 4: Beginning of August (2015) , I had 3 Level III babies; my podmate had 2 Level III babies that were very sick. the charge nurse had a full assignment. When my podmate went to lunch, I was caring for 5 babies with multiple alarms sounding. This was not a safe situation...

RN # 5: In August (2015) , I had three (3) Level III babies and I was the assigned transport nurse. If I had to go to a delivery or to a transport; these babies would be assigned to other staff who already had a full assignment. I didn't feel this was safe...

RN # 6: In the summer we were extremely short staffed. Once, I had 2 very sick Level III babies; my podmate also had 2 very sick Level III babies, plus a new orientee. We are supposed to have a float charge nurse but the charge nurse had 2 babies in Intensive transition ;the transport nurse had a full assignment as well. This was not a safe situation for the patients. This did not happen every day but it also was not a rare occurrence..

RN # 8: A few weeks ago, I had four (4) Level II babies; my podmate had four (4) level II babies. The transport nurse called in sick; so the charge nurse had babies assigned and acted as transport nurse. I had to take a baby to get an MRI ( magnetic resonance imaging) ; which left my podmate watching over seven (7) level II babies...not safe....

2. All nine (9) nurses said they were aware several staff completed Safe Harbor forms multiple times during the summer because they felt the staffing was unsafe. None of the staff could offer feedback or changes made based on Safe Harbor reporting.

3. All nine(9) nurses said the facility made some attempts to address the nursing staffing shortage; but most felt the efforts were not effective. The NICU nurses interviewed said:

The facility assigned task nurses to help feed and change the babies. NICU staff said this was of minimal help; as the task nurses were not trained to provided critical care to these sick babies.

Facility offered bonuses to the regular NICU staff to work extra shifts; however, they often waited until an hour before a shift started to offer the bonus. Staff said many of them have small children and needed to make plans prior to an hour before start of shift.

Five (5) of the 9 RNs interviewed said they worked as many extra shifts as they safely could. Many said they were exhausted, both mentally and physically.

4. All nine(9) nurses said the staffing was acceptable at the present time; but felt it was only because the patient census was low. All expressed concerns over being short staffed when the census increases.

___________________________

Interview on 11-18-15 at 9:15 .a.m.. with NICU Director # 13 she stated the staffing situation began in May 2015 when the average daily census (ADC) rose from 20 to 40. It happened all of a sudden,over 2 to 3 weeks ( fluctuated week to week). She went on to say the facility addressed the staffing situation in several ways:

a. Human Resources Director called all hospitals with NICUs corporation-wide. We offered pay bonuses and housing. None of the hospitals with NICUs could send nurses, as they were busy as well.

b. Division approved increasing agency nurses pay rates and also offered completion bonuses.

c. Facility offered current NICU staff bonuses: sometimes up to a quadruple bonuses. This was decided day by day. NICU Director acknowledged sometimes bonus approval was received immediately prior to shift.

d. Did not accept transfers to NICU from outside hospitals during this time period, with the exception of Mainland, sister hospital.

NICU Director # 13 went on to say she reviewed the NICU staffing in May 2015, based on an ADC of 30. She identified the need for 20 additional FTE ( full time equivalents). At the time; there were only 7 or 8 NICU positions open. NICU Director said she began requesting approval for additional FTEs, four (4) at a time. She currently had 15 open positions; and had hired six (6) new graduate nurses who were in various stages of orientation. In addition, she hired two(2) experienced part time nurses.

NICU Director # 13 said she also had requested the extension of three (3) contract nurses and asked for an additional five (5) contract nurses.

_________________________________

Interview on 11-18-15 at 2:30 p.m. with Chief Nursing Officer (CNO) # 14 she stated that in May 2015 the NICU ADC went from 28 to 50 babies; heavy in the Level III area. CNO said it was an all hands on deck situation. Facility assigned 'task nurses' to assist in feeding babies. HR Director offered triple bonuses to staff to work extra shifts. In addition, facility reached out to the North Texas Division ( NICUs) : offered travel and housing; no one available. Facility increased agency pay rate and offered completion bonuses. Chief Executive Officer (CEO) and Medical Director in daily contact regarding babies for possible early but safe discharge. CNO # 14 went on to say the facility was now being more proactive with respect to staffing for known high risk OB patients.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to implement an effective discharge planning policy/ process. The facility failed to ensure :

* Timely discharge planning for 4 of 10 sampled patients (Patient #3, # 4, # 6, # 7);

* A consistent understanding by staff of facility discharge planning process.

Findings include:

TX 020

Interview on 08-11-15 at 10:45 a.m. with Case Manager ( CM) # 7, she stated that discharge planning was done for every patient. A brief initial interview was conducted within 24 hours of admission to determine home situation, medical equipment, and other healthcare needs. CM # 7 said this initial assessment was documented in the Discharge Planning Progress Notes. CM # 7 said she was unsure if the facility used criteria that would trigger a more comprehensive discharge planning evaluation.

[Clinical records for Patients # 3, # 4, # 6, # 7 were reviewed on 08-11-15]

Patient # 7:

Review of Patient # 7's electronic medical record revealed he was 69 year ld male admitted to the facility on on [DATE] with left sided weakness and difficulty speaking. He was discharged to home on 05-18-15 with final diagnosis of right-sided carotid artery stenosis.

Further review of Patient # 7's clinical record with CM # 7, she was unable to locate any documentation of a discharge planning (DP) assessment or a DC Plan.

Patient # 6:

Review of Patient # 6's electronic medical record revealed she was [AGE] year old female admitted to the facility on 05-14-15 with vaginal prolapse and stress incontinence.

Review of Discharge Planning Note, by CM # 7 , dated 05-15-15 , read: Proposed Discharge Plan: Facility...Facility Type Needed: inpatient rehabilitation facility...

Review of Patient # 6's Discharge Summary revealed she was discharged home on 05-18-15.

Interview with CM # 7 she said Patient # 6's condition must have changed for her to go home instead of a rehab facility. She was unable to locate an updated discharge planning progress note. CM # 7 went on to say the Discharge Plan should have been updated to reflect this change.

Patient # 3:

Review of Patient # 3's clinical record with CM # 7 revealed patient was a [AGE] year old female patient admitted on [DATE] for divertiliculits.

Interview on 08-11-15 at 10:50 a.m. with Registered Nurse (RN) # 3 she stated Patient # 3 was likely to be discharged after lunch.

CM # 7 was unable to locate any documentation of discharge planning in Patient # 3's electronic medical record.

Interview on 08-11-15 at 11:30 a.m. . with Patient # 3, she said she was going home today. She went on to say no one had spoken with her about discharge instructions as yet.

Patient # 4

Review of Patient #4's clinical record with CM # 7 revealed patient was a [AGE] year old female patient admitted on [DATE] for asthmatic bronchitis.

Interview on 08-11-15 at 10:50 a.m. with RN # 3 she stated Patient # 4 would be discharged today if the pulmonary physician saw her.

CM # 7 was unable to locate any documentation of discharge planning in Patient # 4's electronic medical record.

Interview on 08-11-15 at 11:45 a.m. with Patient # 4, she said she was going home today. She went on to say no one had spoken with her about discharge instructions as yet. Patient # 4 said she was unsure if her asthma medications would change or not.

Interview on 08-11-15 at 9:30 a.m. with RN # 6 she stated that the discharge planning process involved the physician writing the discharge order; nursing informed the patient & gave them medication prescriptions and discharge paperwork. She said the case managers made sure the patients had the equipment they needed. RN # 6 said it was not necessary to have a physician order for discharge planning.

Interview on 08-11-15 at 9:45 a.m. with RN # 5 she stated that case management started the discharge planning process. She went on to say that case management made barrier rounds every day. RN # 5 stated she was unsure if a physician order was needed for discharge planning or what might trigger a discharge planning evaluation.

Interview on 08-11-15 at 2:45 p.m. with Lead Case Manager # 4 she stated the case managers documented in Midas every day : UR/ insurance and discharge planning needs updates. She said nursing could view the case management documentation in Midas. Lead CM # 4 said the Medicare Office was not open on the weekends. On Monday mornings the case managers check for triggers for needed referrals, such as home health.

Record review of facility policy titled The Role of Case Management/Social Services In The Discharge Planning Process, revised date 4/11, read: Case managers have the responsibility for overall coordination of the discharge planning process...Procedure: 5.1...a. At the time of admission aspects of the patient's physiological, psychosocial and economic levels are assessed by a nurse ...A discharge planning assessment will be initiated within one working day of receipt of an order for services...

Further review of this same policy failed to reveal a process for ongoing reassessment of the discharge plan based on patient condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility's registered nursing staff failed to supervise the care of patients assigned, in that patients were not provided with care and services prescribed by the physicians in 7 of 44 Patients. #s 15, 22, 34, 37, 38, 39 and 44

Findings :

Patient #15

On 01/15/2014 at 8:27 a.m. patient (# 15) was observed receiving hemodialysis treatment at a blood flow rate of 200 ml/minute and dialysate flow rate of 500 mls/ minute. The patient was utilizing Dialyzer Xenium 170 for her hemodialysis treatment.

Review of the patient's clinical record revealed a physician's order dated 01/14/14 for Dialyzer Xenium 150.

The Surveyor immediately notified the Charge Nurse and the Quality Director who was present that the patient was not utilizing the Dialyzer Xenium prescribed by the physician.

The Charge nurse stated that the patient should be on Xenium 150 and so she will call the physician and notify him that the patient was not on the prescribed dialyzer and secure an order to continue using Dialyzer Xenium 170.

Patient #22

Review on 01/16/2014 of patient ( #22) clinical record revealed a physician's order dated 01/14/2014 for Social worker evaluation for home situation . Lives alone. PRN live in care taker stealing from her. Discharge plan

Interview on 01/16/2014 at 10:15 a.m. with the patient on the dialysis unit, revealed she lives alone, there a male associate who helps her with her two dogs. She said the gentleman had stolen money from her.

The patient said she was not seen by the social worker or the discharge planner.

Interview on 01/16/2014 10:50 a.m. with the Social Work Director, she stated I was not aware of the consultation, it is not a unit I typically check. It is an overflow unit. Whenever social work staff is available they cover that unit.

Patient # #38

Patient #38 was observed on 01/17/2014 at 10:10 a.m. in her room on 4 South. The patient was alert with periods of confusion.

Review of the patient's clinical record ( history and physical dated 01/13/2014 ) revealed the patient was admitted to the facility with history of nausea, vomiting and diarrhea.

Review on 01/17/2014 of the patient's clinical record revealed a physician's order dated 01/13/2014 for stools for C Dif.

Review of the patient's clinical record ( nurses' notes located in the computer) revealed documentation which indicated that the patient had a bowel movement on 01/14/14 and 01/17/14.

There was no documentation that why the patient's stool sample was not collected for C Dif.

Interview on 01/17/2014 at 10:14 a.m. with the RN# 108 who was assigned to the patient revealed there was no documentation why the stool specimen was not collected.

Patient #34

Patient # 34 was observed in her room on 01/16/2014 at 11:58 a.m.. The patient complained of pain in her buttocks and right foot. The patient's right foot was not elevated. Observation of the patient's right foot and ankle revealed it was swollen with some deformity.

Interview on 01/16/2014 at 11:58 a.m. with the patient revealed the doctor had ordered a special boot for her right foot but she did not have it.

Review on 01/16/2014 of patient # 34's clinical record, revealed a physician's order dated 01/13/2014 for Pneumatic walker/ Cam boots. Physician ' s order dated 01/14/2014. Elevate right foot

Review of a podiatrist documentation dated 01/14/2014 revealed the following entry in the patient's clinical record. R durral foot to ankle pain, contusion. Cam boot awaiting

Podiatrist progress notes dated 01/16/2014 at 9:20 a.m. documented : Still no boots. (+ pain ) (R) foot. Multiple right foot fracture. Still trying to get cam walker boot.

Review of the report of a CT of the patient's right foot without contrast revealed the following entry: Small non displaced cortical fractures are identified involving the proximal and distal dorsal cortex of the medial cuneiform -and at least the plantar aspect of the navicular bone at the first cuneonavicular joint. In addition a nondisplaced hairline fracture is identified trans versing the body of the lateral cuneiform bone.

Interview on 01/16/2014 at 12:00 p.m. with the Registered Nurse ( #109) assigned to the patient revealed she had requested the boot for the patient the day before but it had not arrived on the unit. She said she did not know why the boots were not provided for the patient since it was ordered by the physician on 01/13/2014.

During the conversation with the registered nurse assigned to the patient , the boot arrived on the unit and was applied to the patient ' s right foot by the registered nurse assigned to the patient and the Administrative staff accompanying the surveyor.

Patient # 39

Review of medical record revealed Patient # 39 was admitted to the facility on [DATE] and was discharged on [DATE] to a Nursing Home where she was a resident.

Review of history and physical revealed the [AGE] year old patient was seen in the emergency room on [DATE] for abdominal pain. CT of abdomen and pelvis showed gallstones with mildly distended gallbladder. Ultrasound of abdomen showed findings suggestive of acute calculus [DIAGNOSES REDACTED] and umbilical hernia.

Physician examination revealed Patient # 39 had [DIAGNOSES REDACTED]tous rash suggestive of candida infection under both breasts, edema of lower extremities and patchy erythemia.She was alert and oriented x 3 with no focal deficit.

Review of wound images dated10/14/2013 showed multiple rashes on buttocks, legs and under her breasts. There was an order to consult wound care nurse dated 10/14/2013. The patient had a laparoscopic cholecystectomy and an open ventral hernia repair done 10/15/2013.

Wound consult was done on 10/15/2013 with documentation the patient had yeast rash to breast and abdominal fold being treated with nyastatin powder. Recommend xenaderm daily to bilateral lower extremities.

There was no documentation that xenaderm cream was ever used.

Review of wound care documentation revealed documentation dated 10/15/2013, that 4 lap sites on abdomen covered with Dermabond(dressing) and 4 x 4 gauze was clean dry and intact with small amount of drainage.

Documentation on 10/15/2013, 10/18/2013 and 10/19/2013 noted small amount of drainage from JP drain site.

On 10/21/2013 at 00:38 notes documented JP drain site with mild drainage, patient refused dressing change. No documented follow up or teaching re-importance of changing soiled dressing. There was documentation that there was no dressing changes done.

There was no orders for dressing change and no documentation the nursing staff requested an order although there were documentation that there was drainage on the dressing.

Review of physician orders and nurses notes revealed Patient # 39 had a Foley catheter inserted on 10/13/2013 in the emergency room . The patient There was no documentation that an evaluation for continued use of the Foley catheter was done. The catheter was removed on discharge 10/21/2013 seven (7) days after it was initiated.

Review of bath record for Patient # 39 revealed one (1) documented entry that a bath was given on 10/21/2013 date of discharge.

Patient # 44

Review of admission assessment documentation revealed Patient #44 was admitted on [DATE] with history of nausea vomiting and generalized tremor for several days. On admission there was documentation the patient was lethargic, not eating, she had stage two pressure ulcers on right and left buttocks. There was no documentation the patient ' s physician was informed until 1/12/2014 when a wound consult was ordered. The physician made orders for wound care on 1/13/2014 to turn patient every 2 hours, Xenaderm and foam to sacrum daily, and heel protectors to both heels. There was no documentation of nursing intervention for the pressure ulcers prior to 1/13/2014.

Patient # 37

Patient # 37 was admitted on [DATE] with history of diabetes, psoriasis,dementia and decreased range of motion.

Infectious disease physician examination notes dated 1/13/2014 documented the patient had 2+ pedal edema bilaterally, with blisters on the right lower extremity. He had Gangrene of the left great toe and also ischemic ulcers on the other small toes and onchomycosis and discoloration indicative of ischemia of his toes.

Review of nurses notes dated 1/10/2014-1/17/2014 revealed documentation the patient had ulcers on first left toe, first right toe, and fourth left toe. There was no documentation the physician was informed per facility's protocol. There was no documentation nurses obtained an order for wound management and there was no documented nursing intervention.

During an interview on 1/16/2014 at 10:15 am with Staff # 103 RN Manager of the Unit , baths are offered daily and as needed. Patients are bathed on the morning or evening shift. Linen change is done at bath time and as needed. The Manager stated staff is expected to document baths however it has been a challenge to get staff to do so.

According to Staff # 103 when a patient is admitted with pressure ulcer or when one is identified staff is to inform the physician and document on the patient ' s clinical record.

She stated all Foley catheters require a medical indication for use and an evaluation of the indication for continued use. This must be documented on the patient ' s clinical record.

Review of Policy/Procedure dated 5/2012 gave the following information:

Because the majority of nosocomial urinary tract infections are associated with the use of an indwelling urinary catheter, careful evaluation of the initial indication for catheterization and the need for continued catheterization is necessary. Indwelling urinary catheters are inserted only when medically indicated and left in place only for as long as clinically needed due to the potential for complications. Urinary catheters are not used solely for the convenience of patient care personnel.

Indication for use documented as:

Peri-operative and or Diagnostic procedure

Urine output monitoring in critically ill patients

Management of acute urinary retention and obstruction

To assist in pressure ulcer healing for incontinent patients

Gross hematuria/irrigation.

Review of Policy/procedure dated 2/2013 for wound and skin assessment documentation revealed the following information:

A Complete skin assessment and Braden scale risk assessment will be conducted on each patient at admission and every shift. This assessment is to be documented in Meditech. In addition, any wounds found are to be classified staged, measured, and documented. Upon wound discovery notify physician to obtain Routine Wound Management'' orders which are located in e-demand or obtain other treatment options. Interventions should also be included as well as patient response to interventions. Plan of care should also be updated regularly to reflect changes.

All pressure ulcers present on admission should be reported to the physician upon discovery and documented in the admission assessment. Obtain orders for Routine Wound Management Ordrers or other treatment options as specified by the physician.

Based on observation, record review and interview, the facility failed to ensure dietary services were organized in regards to environmental sanitation for 2 of 2 kitchens.

Findings include:

Clear Lake Regional Medical Center (CLRMC)

Kitchen

Observations on 1/14/14 at 9:35 a.m. with the Dietary Director, #81, the Chef #82, and the Dietary Manager #83 revealed the following:

-the floor in cooler #1 was dirty with trash and grime

-in the dry pantry area the floors under the wire racks were dirty with trash, dirt and grime. Several plastic sheaths on the bottom shelves of the wire racks were dirty with grime to touch. There was a brownish dried liquid area under a corner shelf. Chef #82 said it may be prune juice that had spilled and dried.

Further interview with Chef #82, he said up until 3 to 4 weeks ago, they had a porter that cleaned the dry storage area, but he had to be moved to the dish area and other responsibilities.

Further observations of the kitchen at this time revealed the following:

-four convection ovens had a hard, thick build-up of baked on black/brown grease and grime inside and on the doors

-hot boxes with a build up of hard, brown grime, grease and dirt on the sides and hinges

-the grill had a thick build up of hard, black baked on grease and grime.

-floor under the fryer had a thick accumulation of grease and the back splash had a hard, thick accumulation of black baked on grease

-the catch pan under the stove had a one inch thick accumulation of food particles, grease and grime

Interview at this time with Chef #82, he said they were working short staffed. He said the bottom two ovens had been cleaned two weeks ago and the top two should have been done next, but he had to use the staff to help prepare meals. He said an outside company came in twice a week to clean the cooking oil and the fryer. He said the catch pans should be cleaned weekly.

Mainland Medical Center (MMC)

Kitchen

Observation 1/15/14 at 8:35 a.m. of the kitchen revealed the following:

-the fryer had two compartments with a thick build up of black baked on grime/grease in the seams. Two lids for the fryer sections had a thick accumulation of brown baked on grime/grease on the underside of the lids. The fryer had a two-door cabinet underneath. Inside were two foil containers full of grease and a thick build up of grease and grime on the bottom shelf under the containers and on the floor underneath the fryer unit.

Interview at this time with Dietary Director #84, she said the census had been high and they had been a little short of help.

-the tilt skillet had a thick accumulation of grease, grime, and dirt on the support structures, the control dials and on the floor.

-the oven had a thick accumulation of hard, black baked on grease/grime inside the oven, on the door and the back splash.

-the bottom shelf under the convection oven had an accumulation of grease and grime

-four prep tables placed touching in a square had an accumulation of grease and grime on the bottom shelves. The floor under the prep tables had an accumulation of grease, grime and trash.

-the stand up oven had a hard, thick accumulation of black/brown baked on grease and grime inside and outside the unit

-two standing production racks in the cooler had an accumulation of grime on the rims that supported trays.

-the production box had a thick accumulation of food and grime in the edges of the floor by the door. There was an accumulation of dirt and grime on the floor under the shelving.

-the thaw box had a thick build up of food and grime in the edges of the floor by the door.

-in the dry storage area there was an accumulation of grime and trash under two wire racks along one wall.

Interview on 1/15/14 at 1:45 p.m. with Dietary Director #84, she said she used to have a person who worked from 3:30 p.m. to 12 a.m. who just did the heavy cleaning. She said the position had been vacant since some time in November 2013. She said she had been trying to get the position filled. She said the cleaning was done by each person responsible for their area of the kitchen. She said they were down four staff: 1 cook, 1 heavy cleaning person, 1 part-time dietitian and 1 tech.

Observation on 1/15/14 at 1:55 p.m. revealed a two compartment plastic bucket on a lower shelf in the kitchen. Interview at this time with Lead Cook #94, she said she filled the bucket with water on one side and sanitizing solution (quaternary ammonium) from the 3 compartment sink on the other side about one hour ago. A check of the concentration of sanitizing solution in the bucket at this time revealed it was at 100 ppm (parts per million). Dietary Director #84 was present at this time and said the solution should be between 200 and 300 ppm. A check of the sanitation solution from the 3 compartment sink revealed it was between 200 and 300 ppm.

Record review of the Galveston County Health District Inspection Report for Food Sanitation for Mainland Medical Center dated 12/16/13 at 2:10 p.m. revealed compliance was out for Food contact surfaces of equipment and utensils not clean/not sanitized/not in good repair.

2.6 If the sanitizing water is not within the acceptable limits the FSW reports the problem to a supervisor immediately and does not use the dish machine until the problem has been resolved....

CLRMC

Kitchen

Observation at 1/16/14 at 8:10 a.m. with Assistant Administrator #106 revealed a catch pan under the burners of the stove in the steam table section that had an inch of dried, burned food particles, grease and grime.

Interview on 1/17/14 at 9:43 a.m. with Dietary Director #81 for CLRMC he said he had 23 years experience in food service. He said he was in the middle of getting certified as a Dietary Manager. He said he worked for a food company and contracted as the interim Dietary Director in September 2013 for CLRMC. He said he rounded weekly on Tuesdays with Infection Control Nurse #65. He said they looked at dates, labels, and dish washer temperatures. He said they looked at general cleanliness, cooler and freezer temperatures, warmers, food temperatures, ceiling tiles, holes, handwashing, and condition of products.

Interview on 1/17/14 at 9:30 a.m. with Chief Operation Officer (COO) #107 and Assistant Administrator #106, they were informed of the sanitation issues found in the CLRMC kitchen. COO #107 said the facility had an outside company that did the heavy cleaning twice a week. He said they would look at adding another day.

Record review of the Job Description for the Dietary Director reviewed on 8/06 revealed the following:

E1. Responsible for overall management of the FANS (Food and Nutrition Services) Department...

E5. Monitors and evaluates staff, including direct supervision and inspection of employee activities.

Record review of the facilities' Policy and Procedure for Cleaning/Sanitation of food contact Surfaces dated 4/1/11 revealed the following:

5.0 PROCEDURE

Food contact Surfaces

-Countertops and work areas are to be cleaned and sanitized after each meal, as well as throughout the preparation times....

-To sanitize effectively, follow all directions carefully....Use test tapes provided to determine if sanitizing solution is adequate....

5.2 Walk-in Refrigerators, Freezers and Air Curtains

5.2.1 All walk-ins will be maintained for sanitation and safety according to established guidelines.

5.2.2 Walk-in refrigeration units will be cleaned thoroughly weekly. Any visible soil or spills will be cleaned up as they occur....

5.3 Dry Storage...

5.3.1 Inventory Clerk is responsible for ensuring that all racks, floors and items stored are organized and free of dust or debris.

5.3.2 All FANS [Food and Nutrition Service] employees are responsible for ensuring that all storage areas are organized and cleaned daily.

5.3.3 Dry Storage:

5.3.3.1 Storage areas are to be cleaned one section at a time.

5.3.3.2 ....(shelves are to be cleaned monthly or as soon as spills/drips occur)....

5.2.28 Proper cleaning procedures for floors/walls/shelves to be maintained daily and as scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to implement its policy and procedure when discontinuing patient's central venous catheter during hemodialysis treatment; failed to wash/clean hands after direct contact with patients and contaminated equipment, failed to administer antibiotic medication at scheduled times for patient with infection, failed to maintain environmental sanitation in the emergency room and rehabilitation unit, failed to implement its policy and procedure to label a peripheral intravenous line with date and time; failed to apply mask to a patient during insertion of Peripherally Inserted Central Catheter (PICC) and failed to change gloves and wash hands during wound care in 10 of 44 sampled patients . Patient #s 11, 12, 13, 14 , 15, 16, 17, 19, 22, 23)

Findings:

Central Venous Catheter Care

Patient #22

On 01/14/2014 at 10:15 a.m. patient (#22) was observed in the hemodialysis unit of the facility receiving hemodialysis. The patient had a central venous catheter to the jugular region. On 01/14/2014 at 10:20 a.m. Registered Nurse (#80) was observed discontinuing the external blood line from the patient's central venous catheter. During discontinuation of the central venous catheter, the registered nurse applied a plastic apron, donned a pair of gloves, and applied a mask to her face. The nurse used the gloves she had used to mask her face to access the patient's central venous catheter. During application of the mask to her face the gloves became contaminated from direct contact to the nurse's ears and hair

The registered nurse disconnected the patient's external blood line from the hubs of the patient's central venous catheter. Registered Nurse ( # 80) did not clean/ disinfect the hub of the catheter prior to discontinuing it from the external blood lines.

During an interview on 01/14/2014 at 11:05 a.m. with Registered Nurse (# 80) the Surveyor notified her that she did not clean the hub of the central venous catheter before accessing it and that she had used the gloves she had used to apply her mask to her face. Registered Nurse #(80) stated I am sorry.

Patient #15

On 01/15/2014 at 9:15 a.m. Registered Nurse (#72 ) was observed discontinuing patient # (#15's ) external blood line from her central venous catheter, post hemodialysis treatment.

During discontinuation of the catheter the registered nurse was observed wearing a plastic apron which protected the front of her clothing. She was not wearing a gown with sleeves.

During discontinuation of the patient's hemodialysis treatment , the contaminated, bloody blood lines were observed in contact with her arms which were not covered.

During discontinuation of the patient's central venous catheter, the registered nurse did not create a clean field to store the syringe with normal saline and Heparin used to pack the catheter post hemodialysis treatment. Registered nurse ( #72 ) removed the Normal Saline syringes from their wrappers and placed them on the blanket of the patient. She then flushed and packed the patient ' s central venous catheter utilizing the syringes stored on the patient ' s bed. The patient is transferred to the unit in her bed with the blanket which is potentially contaminated.

Review on 01/14/2014 of the facility's current policy and procedure on Discontinuation of Dialysis via Hemodialysis Catheter , # 749- 017 directed facility ' s staff as follows: Wash hands, Place barrier under catheter Y, Rub hub with Chlorascrub swab for 10 to 20 seconds.

Policy # 749- 023 Infection Control - Standards in Dialysis Unit and Cleaning of Equipment directed staff as follows A Septic technique will be used during initiation and discontinuation of dialysis procedure

HAND WASHING

Patient #15

On 01/15/2014 at 9:08 a.m. Registered Nurse ( #72) was observed at the bedside of the patient #15 ( hemodialysis unit) who was receiving hemodialysis treatment. Observation revealed registered nurse (#72 ) donned a pair of gloves and reset the alarms of the patient ' s hemodialysis machine. While resetting the alarms the telephone on the wall rang. She then used her disengaged hand to retrieve the telephone on the wall and spoke to the party on the end of the telephone.

She then removed her contaminated gloves and proceeded to write orders on the patient's clinical record located at the bedside of the patient. The registered nurse used her contaminated hands to touch and handle the hard copy of the patient's clinical record located on the overbed table at the patient's bedside. She did not wash/ clean her contaminated hands after removing the contaminated gloves used to touch and reset the alarms on the patient ' s hemodialysis machine.

Subsequent observation at 9:15 a.m. revealed Registered nurse ( # 72) reset the patient's hemodialysis and handled the patient's blood line. She then removed one hand of her contaminated glove, held it in her left hand while using her right hand to chart on the patient's treatment sheet located on the bedside table. The treatment sheet is filed into the patient's chart post hemodialysis treatment of the patient.

Patient #16

On 01/15/2014 at 9:45 a.m. Patient # ( 16) was observed in the facility's intensive care unit. The patient was receiving hemodialysis treatment via a triple lumen catheter, had a Foley catheter in place to bedside drain .

Interview on 01/15/2014 at 9:45 a.m. with the registered nurse assigned to the patient revealed she was admitted to the facility with a diagnosis of sepsis, urinary tract infection , currently on contact isolation for Clostridium Defficile . The nurse said the patient was on antibiotic therapy of Flagyl and Zosyn.

Subsequent observation on 01/15/2014 at 9:46 a.m. revealed the patient's attending infectious disease physician ( #73) , donned a gown and pair of gloves and entered the patient's room. The physician utilized his personal stethoscope to examine the patient's breath sounds. He then returned the contaminated stethoscope to his laboratory coat which he wore under the gown.

He touched the patient's Foley bag, then removed his contaminated gloves and exited the patient's room.

The infectious disease physician exited the patient's cubicle and entered the nurses' station. He did not wash/ clean his contaminated hands. On entering the nurses' station a nurse offered the physician an alcohol swab to clean his stethoscope. The physician cleaned the stethoscope with the alcohol pad and returned it to his contaminated laboratory coat pocket.

During an interview on 01/15/2014 at 9:50 a.m. with the infection control physician (#73) , the Surveyor notified him that she the Surveyor observed that he had examined the patient and did not wash his hands. He stated You are absolutely right you caught me.

Review of the patient's clinical record ( Physician's progress notes) revealed an entry which as follows : 1/14/14 C diff associated with colitis

Review of the Center for Disease Control article Rationale for Hand Hygiene Recommendations after Caring for a Patient with Clostridium difficile Infection Fall 2011 update documented : alcohol does not kill C difficile spores. In addition several studies have found that handwashing with soup and water or with antimicrobial soap and water, to be more effective at removing Cdificile spores than alcohol based hand hygiene products from the hands of volunteers inoculated with known number of C difficile spores.

Patient #19

On 01/15/2014 at 10:26 a.m. patient # (19 ) was observed in the coronary care unit of the facility. The patient had an endotracheal tube to ventilator and a Foley catheter to bedside drain.

Observation on 01/15/2014 at 10:26 a.m. revealed registered nurse ( #75) was observed providing direct care to the patient and handling the patient's tracheostomy tubes. After completing the care the nurse removed her contaminated gloves and then proceeded to the computer and entered information in the computer. The registered nurse did not clean/ wash her contaminated hands.

Interview on 01/15/2014 at 10:28 a.m. with registered nurse (#75 ) revealed the patient has a diagnosis of sepsis and was receiving antibiotic of Vancomycin.

During an interview on 01/15/2014 at 10;28 a.m. with Registered Nurse (#75 ), the surveyor informed the nurse that she the Surveyor had observed that she did not wash/ clean her hands after removing her contaminated gloves. The registered nurse said she washed her hands before entering the patient's room.

Review of the patient's clinical record revealed a diagnosis of cellutitis of the leg with physician ' s order for Vancomycin 1 gm, every 12 hours and Meropenem I gm every 8 hours.(Meropenem is an ultra-broad-spectrum injectable antibiotic used to treat a wide variety of infections. )

Patient #17

On 01/15/2014 at 11:10 a.m. patient # (17 ) was observed in room 341. The patient had returned from the operating room. Observation at that time revealed Registered Nurse ( #74) was observed handing over the patient's care to the nurse on the unit.

Registered Nurse (#74 ) donned a pair of gloves and retrieved a marker from her pocket. She then used the marker to circle the dressing on the patient's right leg, left leg and sacral area. The wound dressings were saturated with drainage from the post operative sites.

The registered Nurse notified the accepting nurse that the patient had incision and drainage of boils on her right leg, left leg and buttocks and that patient's wounds dressings were saturated. She then outlined the periphery of the drainage on the dressings using her marker. She then returned the contaminated marker to her pocket, removed her contaminated gloves and retrieved the patient's chart with her contaminated hands. Registered Nurse (#74 ) did not clean / disinfect her contaminated hands.

On 01/15/2014 at 11:15 a.m., the Surveyor notified Registered Nurse (#74 ) that she did not clean/ wash her contaminated hands and clean her marker. She stated I can clean it now.

Review of the facility's current policy and procedure on Infection Prevention and Control, # 946-06-001 directed staff as follows: Clean hands are the single most important factor in preventing the spread of pathogens and antibiotics resistance in healthcare settings. Hand hygiene reduces the incidence of healthcare associated infections.

Hand Hygiene is indicated : Before and after touching a patient, Before Clean/Aseptic procedures. After contact with body fluids or excretions, mucous membranes, non intact skin and wound dressings, Before moving from a contaminated - body site to a clean- body site during patient care, After contact with inanimate objects ( including medical equipment) in the immediate vicinity of the patient, After removing gloves, Before meals or eating snacks After personal use of toilet.

MEDICATION ADMINISTRATION

Patient #23

On 01/14/2014 during tour of the facility's CV intermediate Care unit ( Patient # 23) was observed in his room. An isolation cart was stationed outside the patient's room.

Interview on 01/14/20 01/ at 11:45 a.m. with the registered nurse( # 78) assigned to the patient revealed, the patient was admitted to the facility with diagnosis of Sepsis of a wound, but she did not know where the wound was located on the patient. She said the patient was receiving intravenous antibiotic for Vancomycin Resistant Enterococci. She said the patient was on isolation precaution for Vancomycin Resistant Enterococci .

Observation on 01/14/2014 at 11:50 a.m. of the patient revealed he had a left subclavian intravenous line in place. The patient was receiving Flagyl 500 mg intravenous. Hanging on the pole was Maxipen 1 gm in normal saline. The Maxipen was not been infused.

Interview on 01/14/2014 at 11: 52 a.m. with the Registered Nurse ( #78) assigned to the patient revealed the patient should have received Flagyl at 7:30 a.m. and the Maxipen should have been administered at 9:00 a.m. She said the patient was on isolation precaution for Vancomycin Resistant Enterococci.

Review on 01/16/2015 of the patient's clinical record revealed a physician's order dated 01/12/2013 for Flagyl 500 mg in 100 mls Normal Saline . The medication was scheduled to be administered at 7:30 a.m. and infused over one hour.

Review of the Medication Administration Record located in the computer revealed documentation that the medication was started at 10:41 a.m., i.e. three hours and 11 minutes past scheduled medication administration time.

Review of the Medication Administration Record revealed documentation which indicated that the medication, Maxipen was administered at 10:44 a.m. on 01/14/2014. Observation on 01/14/2014 at 11:50 a.m. revealed the medication had not started.

During an interview on 01/14/2014 at 11:52 a.m. with registered nurse ( #78) who was assigned to the patient, the Surveyor told the nurse that she had observed that the patient's antibiotic were not been administered at the scheduled time. Registered Nurse ( # 78 ) said she was Swamped) and running behind because she had five patients and normally she is assigned 4 patients.

emergency room

Observation 1/14/14 at 9:50 a.m. in the emergency department revealed the following:

-In the triage area there was a metal mayo stand with a dried blood stain the size of a penny.

-In the fast-track holding area dust / lint was noted on top of the cardiac monitors in room # ' s 1, 2, 3 and 4.

-At the nursing station three fabric chairs were noted to be heavily stained on the back portion. The arms of the chairs were also heavily stained.

-Treatment room # 18 had an overhead light used for suturing and the top surface was covered with a dust and lint.

-A vinyl chair was observed outside room #4 in the hallway. The vinyl in the seat of the chair had a 3 inch tear in the vinyl.

Rehabilitation Unit

Observation on 1/14/2014 at 10:50 am on 5 East Rehabilitation Unit at the facility revealed there was eight (8) semi private rooms and 16 patients. The unit was at capacity at the time of observation.

Further observation at that time revealed patient rooms were cluttered with various types of dusty exercise equipment.

The floor of patient rooms, hallways and the exercise gym had a dull discolored appearance with black streaks through the tiles possibly from a buildup of wax and dirt. There was a buildup of dust grains in the corners of the floors.

Doors to patient rooms had large chips and there were cracks in wall sidings in the hallway.

Observation revealed hand sanitizer dispensers mounted on walls inside and outside patient rooms had heavy build up of dust grains and dust webs at the base and on the tops.

Exercise equipment in the gym such as the light weight thread mil, parallel bar, standing frame and large exercise balls had heavy buildup of dust grains, dust webs and grease. Computer cart was also greasy and had a buildup of dust.

During an interview on 1/14/2014 at 11:15 am Staff #104 Unit Manager he stated the floor need stripping but the unit was constantly at capacity and it was difficult to get the cleaners in. The manager acknowledged the Unit needed cleaning and stated staff would get on it right away.

During an interview on 1/14/2014 at 1:35 pm with Staff # 68 RN Director who was touring with the Surveyor at the time of the observation, she stated a meeting was convened with housekeeping supervisor and staff on the Rehabilitation Unit and staff were assigned to immediately clean the unit. She stated a plan for continued cleaning and monitoring would be implemented.

Failed to implement its policy and procedure to label a Peripheral Intravenous line with date and time; failed to apply mask to a patient during insertion of Peripherally Inserted Central Catheter (PICC), failed to change gloves and wash hands during wound care.

Findings:

Registered Nurse #(68)

On 01/15/2014 at 10:00a.m. Surveyor was in the Medical Surgical 5th floor unit for tour. During an observation and interview in Room 560, patient (11) stated I am ready to go home today. Noted a Peripheral Intravenous line (IV) on Left upper arm without date and time of insertion. The Surveyor asked the patient when was it inserted, she said This IV line was started on January 12 when I was at the Emergency Center in Pearland then I was admitted here, and they are using the same IV line. Surveyor called one of the hospital's Medical Surgical Directors (#68) seen the patient's IV that had no date and time of insertion.

During observation on 01/15/2014 at 10:35 a.m. the Surveyor went to Room 561 and interview patient (12), noted a Peripheral Intravenous line (IV) on Left lower arm without date and time of insertion. The Surveyor asked the patient when was it inserted, she said It was placed yesterday. Surveyor called one of the hospital's Medical Surgical Directors (#68) seen the patient's IV that had no date and time of insertion.

During record review on 1/15/2014 at 10:45 a.m. the Surveyor requested patient (#11) chart, admitted on [DATE] due to flank pain, no assessment note about Peripheral IV. Record review on 1/15/2014 at 10:55 a.m. the Surveyor requested patient (#12) chart, it showed the patient admitted on [DATE] due to small bowel obstruction, no assessment note about Peripheral IV. The Surveyor asked for a policy about IV Therapy, the hospital's Medical Surgical Director (#68) provided a copy of policy title : IV Therapy in section 5.3 Procedure 5.3.21 stated Label dressing with date, time, and size of needle.

Registered Nurse # (70)

On 01/15/2014 at 01:10 p.m. Surveyor was in the Radiology room to watch the PICC line procedure. Registered Nurse (#70) was observed preparing patient (#13) for PICC line insertion in Radiology room, drape was applied on the patient's body but no mask. PICC line insertion began by Registered Nurse (#70) at 01:15 p.m and ended at 01:35 p.m the patient did not wear a mask.

During an interview conducted on 1/15/2014 at 1:40 p.m with Registered Nurse#70, the Surveyor verified if the patient needs to wear mask during PICC line insertion, she said It is not in included in our PICC line insertion policy.

During record review on 1/16/2014 at 08:30 a.m. Surveyor requested hospital's policies and procedures related to PICC line insertion, at 08:50 a.m. from one of the hospital's Cardio Vascular Directors (#66) provided Policy Title: 600-133 PICC-Insertion ,Maintenance, and Removal for Adult patients (MAINLAND CAMPUS ONLY) Section 4.2 bullet #8 says The patient's face should be draped and/or patient should wear mask.

On 1/17/2014 at 11:30 a.m. The Surveyor received another hospital's policies and procedures related to PICC line insertion, from one of the hospital's Critical Care Service Line Director (#54) provided Policy Title: 600-133 PICC-Insertion ,Maintenance, and Removal for Adult patients Section 8.0 under 8.2. PICC/Midline to be inserted using maximum barrier precautions. Surveyor verified with the hospital's Critical Care Service Line Director (#54) about the meaning of maximum barrier precautions, and she replied The PICC team uses Lippincott procedure for PICC line insertion, the hospital's Critical Care Service Line Director (#54) provided the copy of the Lippincott procedure handed to Surveyor page 5 bullet # 21 says Place a full body drape over the patient from head to toe. Cover everything except the insertion site to comply with maximal barrier precautions and, therefore, reduce the risk of central line related blood stream infection. Surveyor asked if which among these two policies is used by the hospital she replied This one that I gave you because the other one is for Mainland Campus only.

Registered Nurse #(96)

On 01/16/2014 at 09:35 a.m. The Surveyor was in the Medical Surgical 5th floor unit to watch wound care procedure. Registered Nurse (#96) was observed removing old wound dressing in patient (14) then picked up a clean soaked gauze with Dakin Solution using the same gloves, she removed the contaminated gloves then took another pair of clean gloves without hand hygiene in between.

During an interview on 01/16/2014 at 09:43 a.m with Registered Nurse (#96) , the Surveyor told her that hand hygiene was missed in between of performing wound care she stated I washed my hands prior to starting this entire procedure, the Surveyor verified procedure about wound care that is followed in the hospital and she answered I follow whatever the doctor's order in the chart. Surveyor clarified to Registered Nurse JW that hand hygiene must be performed in changing gloves she replied Yes you are right.

During record review on 1/16/2014 at 10:00 a.m. The Surveyor requested hospital's policies and procedures related to wound care, at 10:05 a.m. from one of the hospital's Medical Surgical Directors (#68) she said We follow Lippincott Procedure about wound care, she provided a copy of a Lippincott procedure titled Moist Saline Gauze Dressing Application pages 3 to 4 bullets #2 and 3 say put on gloves and other personal protective equipment, Discard the soiled dressing, inspect the wound, remove and discard your soiled gloves, perform hand hygiene and put a new pair of sterile or clean gloves, as indicated.